Background: Care transitions between hospitals, nursing homes, and home are a vulnerable time for patients.  Given the increasing elderly population and the shortage of primary care physicians with training in geriatrics or nursing home care, there is a growing need to identify organizational systems to optimize physician practice, enhance quality of care and increase educational [...]

Background: Hospital admissions are stressful for adults with dementia and their caregivers. During care transitions from hospital to home, outcomes for adults with dementia depend, in part, on the caregiver’s health and well-being. We aimed to identify the resources and training needs of dementia caregivers during care transitions. Methods: We conducted semi-structured interviews with licensed [...]

Background: The transfer of patients between hospitals, known as inter-hospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Despite these poor patient outcomes, best practices to guide IHTs are lacking. To characterize the IHT process and identify key challenges [...]

Background: Existing research describe older adults’ sub-optimal experiences of the hospital to skilled nursing facility (SNF) transition. However, these studies do not explore the causes of these poor experiences and neglect the complex clinical system in which these transitions occur. Therefore, the aims of this study were to identify the causes of patient experiences during [...]

Background: The transfer of patients between hospitals, i.e., interhospital transfer (IHT), introduces discontinuity of care including gaps in information transfer, which may worsen patient outcomes. In this study we aim to identify gaps in information exchange during IHT of medical patients from transferring hospitals of varying affiliation and electronic health record (EHR) integration to a [...]

Background: Inter-hospital transfer (IHT) care is complex and suffers from inefficiencies in information and task organization, which can contribute to high cognitive load for clinicians.[1-4] Cognitive overload can lead to medical errors and clinician stress.[5-8] Our study identifies specific areas of high cognitive load experienced by hospital medicine physicians and advanced practice providers (APPs) who [...]

Background: Older adults are commonly discharged to skilled nursing facilities (SNFs) after hospitalization. It is not known how patients anticipate SNF discharges and what they prioritize. The aims of this study are to explore what matters most to older adults during their hospital to SNF care transition. Methods: We conducted a grounded theory qualitative study. [...]

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: Effective teams share common attitudes, behaviors, and cognitions that support teamwork. Within patient safety literature, effective teamwork is a core feature of interventions that reduce adverse events. However, research on teamwork in healthcare has focused on teams of healthcare professionals and has not examined how patients and their family caregivers experience teamwork as part [...]

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 [...]