Background: The Palo Alto VA Hospital has an interdisciplinary Clinical Command Center (C3) that includes “Flow” nurse practitioners (NPs) who work closely with case management, social work and primary medical teams to identify and address barriers to care and assist in discharge planning and coordination. We have created a novel collaboration between a C3 Flow [...]

Background: Care of complex patients are a daily challenge in the hospital setting, with a direct impact on the health care costs. Although there is no standard definition of a “complex” patient, we can argue that they are patients who need more time and resources during their care process. Age and comorbidities are probably important [...]

Background: Patients who are frequently admitted to Medicine inpatient services comprise a distinct subset of readmitted patients about whom not much is known. A prior study collected data on characteristics of 153 frequently hospitalized patients. This was a follow-up evaluation to determine the categories of patients the original cohort belonged to, and to collect mortality [...]

Background: Case Managers (CM) are now a standard presence in emergency departments (ED) of large hospitals, partnering with ED and Hospital Medicine providers to improve care. They are integral in improving hospital throughput and reducing unnecessary hospital admissions and readmissions. Case Managers generally identify high-risk patients using a manual chart review process or by provider [...]

Background: A process problem with our MDR process was identified which had exhausted conventional unit-based approaches to improvement. We researched new processes and brainstormed on an “outside the box” approach to the Case Management model and MDR Daily Meetings. The new approach involved a dramatic Hospital-wide change of structure, associated with integration of multiple service [...]