Background: Transition home after hospitalization carries significant risk of adverse patient events, readmissions and increased costs. Despite significant organizational efforts to improve care transitions, there continue to be challenges in implementing consistent interventions that impact key metrics of patient experience with the care transition and 30-day readmission rates. Purpose: Designing patient-centered systems which improve collaboration [...]

Background: Many patients are discharged from the hospital to post-acute rehab in a skilled nursing facility (SNF). These care transitions can be error-prone, hampered by inadequate patient preparation for rehabilitation and insufficient communication between care providers. The readmission rate from SNF was 23.5% in 2006, costing Medicare $4.34 billion. Prior studies show 30% of these [...]

Background: Patients who are at risk for readmissions and emergency department visits following hospital discharge frequently have multiple medical comorbidities and a history of multiple prior hospitalizations. Over the past five years, reducing hospital readmissions has increasingly become a priority for hospitals, and effective interventions to reduce readmissions have included multiple components and multiple disciplines. [...]

Background: Health literacy (HL) is the measure of a person’s ability to obtain, process and understand basic health information and services to make appropriate health decisions.1 Previous studies note positive correlation between high HL and patient understanding of their condition.2 Patients with low HL have greater needs in transitional care domains, citing inadequate caregiver support [...]

Background: Diabetes mellitus is common among hospitalized patients. An inpatient diabetes management service (IDMS) was implemented at a community hospital in suburban Maryland to provide better glycemic control for inpatients. Purpose: To analyze the length of stay (LOS) and 30-day readmission rate (30DR) of patients co-managed by an IDMS team. Description: We retrospectively analyzed LOS [...]

Background: Health literacy (HL) is the measure of a person’s ability to obtain, process and understand basic health information and services to make appropriate health decisions. Previous studies note positive correlation between high HL and patient understanding of their condition. Patients with low HL have greater needs in transitional care domains, citing inadequate caregiver support [...]

Background: Hydroxyurea is an FDA approved medication for use in adults with sickle cell disease. Clinical guidelines, based on high quality evidence, recommend its use in all adults with sickle cell anemia and 3 or more moderate to severe pain crises within one year.  Studies suggest its use to be inappropriately low. We assessed local [...]

Background: Hospital medical groups use various staffing models which systematically affect care continuity during the admission process. Our service changed models of care from a “general model”, where hospitalists who perform hospital rounds and discharges also perform admissions on the same service day, to an “admitter-rounder model”, where service work is divided each day between [...]

Background: Patients discharged to post-acute care facilities are at higher risk for re-admissions compared to those discharged home. Mount Sinai Hospital (MSH) discharges a significant number of patients to Terence Cardinal Cooke Health Care Center (TCC), a post-acute care nursing facility in Manhattan. In 2013, MSH discharges by the hospitalist service to TCC had an average [...]

Background: The Center for Medicare and Medicaid Services (CMS) uses 30-day readmissions as a measure of quality for a hospital system. However, there is growing literature that 30-day readmissions may not be a good measure of quality since most readmissions towards the end of 30-day window are likely not preventable. Therefore, using a shorter window [...]