Background: Discharge to post-acute care settings (PACs), such as skilled nursing facilities (SNFs), requires significant, complex discharge planning which often needs to be started early during hospitalization to be complete by time of discharge. This study sought to identify and model factors which predict a given patient’s likelihood of requiring PAC after discharge, using routinely [...]

Background: New hospitalists can often feel overwhelmed by learning system practices, navigating difficult dispositions, and managing difficult patient and family relationships. This can lead to increased length of stay1, increased burn out, and a feeling of lack of mentorship. Purpose: We hypothesized that weekly meetings between a hospitalist director and a junior faculty hospitalist to [...]

Background: Patients hospitalized with COVID-19 can clinically deteriorate in the second week of illness after a period of initial stability. Thus, an important clinical question is determining when it is safe to discharge these patients from the hospital without overwhelming hospitals’ capacities. Unfortunately, discharge criteria for COVID-19 patients are often based on expert opinion, with [...]

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 [...]

Creating a Best Practice for Discharges Against Medical Advice Background: Nationally, 1-2% of medical discharges from hospitals are against medical advice (AMA).  Patients that leave AMA are at higher risk for readmission and adverse health events.   At our facility, FY 2014 data revealed that 1% of discharges from the medical/surgical wards were AMA.  The 30 [...]

Background: Delays in the discharge process of hospitalized patients impact patient flow and lead to increased costs and slower progression of care. As hospitalist work becomes increasingly shift based, there are concerns for proper patient handoffs and hesitancy with clinical progression of care overnight. This leads to daytime patient flow congestion and is a significant [...]

Background: The Improving Pediatric Patient-Centered Care Transitions (IMPACT) Multi-site Quality Improvement Collaborative aims to improve discharge transitions by testing a patient-centered transition bundle. Teach-back is a core component. This is a well-established method of confirming understanding. However, limited evidence exists about the effect of using teach-back for pediatric discharge education on parental knowledge/understanding of essential [...]

Background: Hospital discharges can be complex for patients, and ensuring patient comprehension of their clinical records and discharge summaries is critical for improving health-related outcomes. However, studies suggest that 88% of discharge instructions are not readable to the population served. In our prior study we demonstrated that generative AI (AI) has the potential to transform [...]

Background: Hospitalized patients and their families often face challenges in accessing and understanding developments in care plans, test results, and interdisciplinary decisions made during their stay. This knowledge gap causes anxiety, confusion, and missed opportunities for shared decision-making. Enhanced interdisciplinary communication and transparency with patients positively impacts patient satisfaction, readmission rates, patient safety and adherence [...]

Background: Previous studies have documented discriminatory refusals from post-acute care facilities related to opioid use disorder or opioid agonist therapy, however the impact of inability to secure skilled nursing facility (SNF) placement for patients with any substance use disorder (SUD) has not been fully explored. The objective of this study is to measure the odds [...]