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: 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 [...]

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: Discharge delays occur because of inconsistent communication among all clinicians and providers. Inefficient utilization of resources also contributes to delays. Effective communication among the patient care team is a foundation of creating an effective discharge planning process. We must standardize the process of communication as well as resource optimization in order to provide our [...]

Background: Nearly 6 million pediatric patients are discharged from the hospital yearly in the United States (AHRQ 2012), and social determinants of health (SDoH) impact discharge outcomes (Nacht 2022). Effective discharge planning prevents patient readmissions (Shapiro 2021), but the literature on how best to educate pediatric trainees is limited (Key-Solle 2010, Widmer 2015). We assessed [...]

Background: Inconsistent transitions of care from the inpatient to outpatient setting may lead to preventable readmissions. Critical processes completed at discharge shown to reduce readmissions at our institution include admission and discharge medication reconciliation, clinically appropriate follow-up scheduled prior to discharge, and timely completion of a discharge summary within 48 hours of discharge (the “Core [...]

Background: Communication between Hospital Medicine physician teams and interdisciplinary care providers (e.g. nurses, physical and occupational therapists, case managers) regarding disposition planning is often inconsistent, potentially delaying care and resulting in poor patient and provider experience. Prior studies demonstrate that sharing the estimated discharge date (EDD) early in a patient’s hospitalization can improve communication and [...]

Background:  Children and Young Adults with Special Healthcare Needs (CSCHN), especially those with multiple organ systems involvement, experience frequent and often lengthy hospitalizations. Hospital discharges for these children can be a complicated process that requires a deliberate, multistep approach and coordination among multi-disciplinary team members. Previous studies have demonstrated that homecare is a cost-effective measure [...]

Background: Understanding patient readiness for discharge requires communication between the many disciplines who care for patients. Team members use different tools in the electronic health record (EHR) to document and communicate discharge-related information, which can result in inefficient communication, delays in discharge, and adverse patient outcomes. EHR-based discharge coordination tools have potential to improve discharge [...]