Background: Executing safe transitions of care for hospitalized patients is important because of the vulnerability of patients during this time period.  While hospital-based providers frequently schedule appointments on behalf of their patients prior to discharge, cancellations and non-attendance (“no-shows”) for post-discharge follow-up appointments are anecdotally common and diminish the quality  of patient care.  Little is [...]

Background: Executing safe transitions of care for hospitalized patients is important because of the vulnerability of patients during this time period.  While hospital-based providers frequently schedule appointments on behalf of their patients prior to discharge, cancellations and non-attendance (“no-shows”) for post-discharge follow-up appointments are anecdotally common and diminish the quality  of patient care.  Little is [...]

Background: Provider continuity can improve many aspects of an inpatient stay however, there is a lack of data on whether it could affect mechanical ventilation weaning. During the COVID-19 pandemic, many patients required tracheostomies and mechanical ventilation. This study evaluated whether provider continuity could increase mechanical ventilation weaning outcomes in the inpatient setting. Methods: Data [...]

Background: Many pediatric hospitalist programs in community hospitals around the country function with a 24-hour shift model for 24/7 coverage. This creates significant discontinuity and daily inefficiencies in patient care. Furthermore, there is a robust amount of adult literature that points to the benefits of both inpatient and outpatient continuity of care. When our community [...]

Background: There is a population of patients who visit Emergency Department (ED) frequently and this has become a challenge for the health-care system. A small proportion, four percent of ED patients, could constitute up to 20% of ED visits (1-3).Interdisciplinary approach of care management is the most widely evaluated and single-point-of contact (4).We conducted a [...]

Background: Outside Medical Records are essential for accurate continuity of care when patients are transferred from one healthcare system to another. Despite their importance, obtaining records in a timely manner is a notoriously difficult process. At Stanford Hospital, the medicine teams were burdened with 5 pages of paperwork per record request for a single patient. [...]

Background: Transitions from hospitals to the ambulatory setting are high risk periods for patients. Many interventions have been tried, with varying degrees of success, and often the problem has been with implementation rather than theoretical efficacy of the intervention.Methods: We developed, implemented, refined, and evaluated a multi-faceted, multi-disciplinary transitions intervention across two hospitals and 18 [...]

Background: Patients recurrently admitted to the hospital frequently experience fragmentation of care and poor health outcomes, with discontinuity between hospital admissions resulting in unnecessary testing, ineffective or inconsistent treatment plans, patient/provider frustration, and inability to address the underlying medical and psychosocial issues that drive repeat hospitalization. Purpose: For patients with the highest inpatient utilization on [...]

Background: Transitions from hospitals to the ambulatory setting are high risk periods for patients. The advent of the Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) provide an opportunity for true collaboration in which both inpatient and outpatient providers contribute to improving transitions in care. The goal of this study was to develop, implement, [...]

Background: Prolonged hospitalizations of patients who are medically ready for discharge are highly prevalent in the current acute care environment.1 Patients who remain in the hospital beyond resolution of their acute medical needs often have high medical, social and psychiatric complexity and are poorly served remaining in an environment that is not designed for their [...]