Background: Hospital readmission rates are heavily scrutinized, and are utilized as a measure of the quality of care provided by hospitals. In the Oklahoma City Veterans Affair Health Care System (VAHCS), there was a significant increase in the number of cardiorespiratory 30-day readmissions in the month of September (8% to 14%). Most patients (76%) were [...]

Background: Hospital discharge is a complex process that requires coordination from various parties. There still remains a significant rate of readmission, with a reported 30 day readmission of roughly 20% and annual cost of $18 Billion to Medicare. Patients with adequate discharge planning have a decreased readmission rate. Recent studies that demonstrated that high risk [...]

Background: In 2011, ~3.3 million adult 30-day US hospital readmissions generated $41.3 billion in hospital costs. $8.26 billion (20%) of this was considered preventable. Numerous studies demonstrate relationships between hospital readmissions and social determinants of health (SDoH). Lack of education, socioeconomic status, and lack of social support have all been cited as core contributors to [...]

Background: In a learning healthcare system, data collected as part of routine care is used to fuel innovation and improvement. Predictive models for post-discharge adverse events have relied on data that is available prior to hospital discharge. Post-discharge care (e.g. appointments, phone calls) can be collected from electronic health records and may impact patient risk [...]

Background: Care fragmentation is associated with a number of clinical and socio-demographic features which have been thought to increase hospital utilization as well as morbidity and mortality. Patients who receive fragmented care at the hospital level are often underinsured and uninsured. It is unclear to what degree lack of insurance and subsequently lack of continuous [...]

Background: The United States government has made decreasing 30-day unplanned readmissions a national priority, as early hospital readmissions are a common and costly occurrence. Establishment of the Hospital Readmission Reduction Program (HRRP) in 2012 led to financial penalties to hospitals with high 30-day readmission rates. As such, decreasing 30-day unplanned readmissions has become a key [...]

Background: Our 165-bed community hospital is in a phase of rapid growth due to demographic changes and expansion of services offered within the hospital. While offering unprecedented level of healthcare access to the community, improvement with emergency department (ED) throughput has emerged as one of our challenges from a patient safety perspective. Unnecessarily prolonged ED [...]

Background: Measures to reduce hospital readmissions help to improve the quality of care patients receive, as well as reduce healthcare costs. The Institute for Healthcare Improvement’s Triple Aim of improving the quality of care through standardization, decreasing the cost of care by reducing hospital utilization, and patient-centeredness around transitions of care, resonate strongly with readmission [...]

Background: Congestive heart failure (CHF) is a major cause of mortality and morbidity among general population despite recent advancements in goal-directed therapies. The advent of mechanical circulatory devices, the increased availability and improvement in heart transplant techniques have improved some metrics; however, CHF patients continue to have multiple readmissions for acute exacerbations. The frequency of [...]

Background: Despite significant efforts, sepsis remains a common cause of hospital readmissions nationwide, and patients are often readmitted within two weeks after their index admission. Not only are patients who develop sepsis often chronically debilitated, sepsis can lead to systemic sequelae that includes functional deconditioning, cognitive impairment, sepsis-induced immunosuppression and inflammation, and cardiovascular risks. This [...]