Background: Frequently hospitalized patients represent a vulnerable population due to discontinuity between episodes of inpatient, outpatient, and specialty care. This discontinuity puts patients at risk for unnecessary over-treatment, dangerous under-treatment, medication errors, and loss of trust due to conflicting messages from healthcare providers. Providers face rising clinical volumes, decreasing familiarity between providers, and ever more [...]

Background: In the US, a small number of patients with complex medical and psychosocial needs disproportionately consume healthcare resources. At our institution, the HOME Program provides dedicated Individualized Care Plans (ICPs) and care coordination for patients with a range of chronic illness. Among such illnesses, Type 1 Diabetes Mellitus accounts for a large portion of [...]

Background: The proportion of young adults with complex medical needs and chronic illnesses cared for at pediatric hospitals is substantially increasing. ACGME requires both pediatric and Internal Medicine (IM) residents to manage patients with complex or chronic conditions and coordinate care across the healthcare continuum, including transitioning to adult care. However, barriers to transitioning these [...]

Background: Caring for multiple patients with complex needs, especially those with behavioral and psychosocial challenges, can contribute to burnout and dissatisfaction in clinical work [1]. A recent internal survey of hospitalists within our division identified managing such patients as the primary barrier to sustainable clinical work. However, the definition of “complexity” varies between hospitalists and [...]