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 [...]

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: Adverse drug events (ADEs) are common during transitions from the hospital to the ambulatory setting, with approximately 20% of patients experiencing an ADE within 30 days of discharge. ADEs are often due to patient misunderstanding of the prescribed medication regimen or non-adherence to the regimen.  New approaches are needed to address this problem. Purpose: [...]

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 [...]

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: 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: Inefficiencies in the hospital discharge process can be a source of patient and provider dissatisfaction. Further, gaps in post-discharge care have been associated with increases in 30-day mortality and 30-day unplanned re-hospitalization. Addressing these gaps requires a specific focus on the development of a post-acute care treatment plan, identification of potential barriers to the [...]

Background: Hospital readmissions are common, detrimental for patients and associated with significant costs for the healthcare system. The aim of this study was to evaluate Charlson, Charlson age, simplified HOSPITAL and LACE score in 30-day non-elective readmission prediction at a Brazilian tertiary care teaching public hospital in Southern Brazil. Methods: Retrospective cohort study including all [...]

Background: Hospital readmissions are common, detrimental for patients and associated with significant costs for the healthcare system. The aim of this study was to evaluate simplified HOSPITAL score (Aubert et al, 2017) in 30-day non-elective readmission prediction at a Brazilian tertiary care teaching public hospital in Southern Brazil. Methods: Retrospective cohort study including all hospital [...]