Background: Heart failure (HF) hospital readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with HF negative clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet [...]

Background: According to Medicare Payment Advisory Commission, about 75% of hospital readmissions are potentially preventable, representing an estimated $12 billion in Medicare spending. Prompt follow-up of hospital patients before primary care and subspecialist appointment may decrease readmissions.Methods: This is a prospective single-site cohort study.We developed a Transitional Medical Clinic (TMC) at Mission Hospital (Mission Viejo, CA) to [...]

Background: Heart failure (HF) is a major public health concern that affects over 5 million adults in the US. HF is among the most common reasons for hospital admissions and presents a considerable cost burden to the medical system. Patients are stabilized and carefully monitored at the hospital but often go home without adequate follow-up [...]

Background: According to a report of the Healthcare Cost and Utilization Project (HCUP) that looked at hospital admissions in 2013, the care of hospitalized malnourished patients costs twice as much as those without malnourishment due to prolonged hospital stays and increased readmission rates. Furthermore, up to 30 to 50 percent of patients are malnourished upon [...]

Background: The period following hospital discharge is a vulnerable time for patients when increased self-care requirements are common. Low levels of health literacy and social support are thought to contribute to poor post-discharge outcomes. However, little research has specifically examined the role of health literacy alone or in combination with social support in predicting readmission [...]

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: Recurrent hospitalizations are responsible for considerable health care costs. This retrospective observational study was undertaken to determine whether timely communication of care (COC), such as direct phone call or voicemail notice, following a hospitalization is effective at increasing clinic follow-up rates and reducing readmissions within 30 days after discharge. Methods: We analyzed 237 patients [...]

Background: The simplified HOSPITAL score is an easy-to-use prediction model that accurately identifies patients at high-risk of 30-day unplanned readmission before hospital discharge. The predictors include the last available hemoglobin and sodium levels at discharge. Because an earlier stratification risk of readmission would allow more preparation time for transitional care interventions, we aimed to assess [...]

Background: Studies have shown about 2 million patients are readmitted to hospitals nationwide yearly. Data from the Center for Health Information and Analysis (CHIA) estimate the annual cost of readmissions of Medicare patients amounts to billions of dollars annually; about half this cost may be preventable. Hospitals are working to create programs to decrease readmission [...]

Case Presentation: A 76 year-old male with a history of diverticulitis, T2DM, HTN, persistent atrial fibrillation and compensated alcoholic cirrhosis presented for recurrent gastrointestinal bleeding (GIB). He initially presented to an outside hospital six months prior for shortness of breath and found to be anemic requiring 4 units of packed red blood cells (PRBCs). Since [...]