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: 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: Virtual care is becoming a fully realized modality of providing patient care (1, 2). In hospital medicine, the transition of care from inpatient to outpatient can be challenging to carry out efficiently and effectively while mitigating any preventable harm that may arise prior to a scheduled follow-up appointment with a primary care physician (PCP). [...]