Background: Patients diagnosed in-hospital with acute venous thromboembolism (VTE) are at high risk for post-discharge complications and readmission similar to patients with chronic conditions. Patient navigation reduces post-discharge complications and readmissions in patients with chronic diseases, however its role in acute conditions is less clear. Similarly, the use of mobile technology to improve patient engagement [...]

Background: Many patients are discharged from the hospital to post-acute rehab in a skilled nursing facility (SNF). These care transitions can be error-prone, hampered by inadequate patient preparation for rehabilitation and insufficient communication between care providers. The readmission rate from SNF was 23.5% in 2006, costing Medicare $4.34 billion. Prior studies show 30% of these [...]

Background: Transitioning from inpatient to outpatient care is high-risk, often associated with harm from incomplete or ineffective communication of clinical information [1]. In one report, 41% of patients had at least one pending study at the time of discharge, 43% of which were abnormal and 9.4% potentially actionable [2]. The discharge summary is a ubiquitous [...]