Background: Coordination of inpatient and outpatient care is an important challenge in improving population health but evidence examining the effectiveness of existing care coordination programs is mixed. The Comprehensive Care Physician (CCP) Program at the University of Chicago provides patients at increased risk of hospitalization the opportunity to receive inpatient and outpatient care from the [...]

Background: Poor coordination between hospital and outpatient care worsens health outcomes, and increases preventable hospitalization and health care expenditures, especially for socioeconomically disadvantaged populations. Evidence of the effects of current programs to improve care coordination is mixed, and there is little data on how their impact may differ for hospitalizations for ambulatory care-sensitive conditions (ACSCs) [...]

Background: Coordination of inpatient and outpatient care is an important challenge in improving population health but evidence examining the effectiveness of existing care coordination programs is mixed. The Comprehensive Care Physician (CCP) Program at the University of Chicago provides patients at increased risk of hospitalization the opportunity to receive inpatient and outpatient care from the [...]

Background: Third and fourth year medical students’ experience on general internal medicine ward teams is an integral part of medical student education. At many institutions this experience includes participation in unit based Care Coordination Rounds (CCRs), including our own. These daily multidisciplinary discharge planning meetings are ubiquitous, however students are often uncomfortable presenting at these [...]

Background: Early discharges from inpatient units improve throughput from the Emergency Department (ED) and reduce ED boarding. ED boarding increases patient safety events, provider burnout, and decreases patient satisfaction. Multidisciplinary communication between hospitalists, nursing staff and case management is essential for facilitating early discharges from inpatient medicine units. Such communication frequently requires in-person care coordination [...]

Background: National readmission rates for all-cause hospitalizations are as high as 14 readmits per 100 index admissions and have been relatively unchanged for at least the last 5 years (Fingar K, et al. Agency for Health Care Policy and Research, 2015). Since January of 2013, the Centers for Medicare & Medicaid Services has adopted a [...]

Background: The transfer of patients between hospitals, known as inter-hospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Despite these poor patient outcomes, best practices to guide IHTs are lacking. To characterize the IHT process and identify key challenges [...]

Background: Millions of people are hospitalized in the United States annually and many of those patients are medically complex requiring a team-based approach to care for their medical problems and complex planning for discharge and the transitions thereafter. The process of discharging a patient is multilayered, time-consuming, and arguably one of the most pivotal times [...]

Background: The division of the hospital medicine at the University of Florida has 52 attending hospitalist physicians with an average daily census of 200 patients. On any given day, one physician carries 16 patients and practices direct care services. This includes chart review, placing orders, answering pages, coordinating with case managers, requesting consultations, rounding on [...]

Background: Patients, particularly the elderly and those who have chronic illnesses, often experience adverse events when transitioning from the hospital to home. An estimated 20% of all discharged patients suffer a preventable adverse event (e.g., reaction to medication) within three weeks of discharge and 20% of Medicare patients are readmitted to the hospital within 30 [...]