Background: Advance care planning can be challenging for both patients and providers.  Barriers to understanding patients’ goals of care include patient and provider discomfort with the topic, as well as family and cultural dynamics.  The Stanford Letter Advance Directive (LAD) is a simple tool written at a fifth grade reading level in eight different languages [...]

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: Advance care planning can be challenging for both patients and providers.  Barriers to understanding patients’ goals of care include patient and provider discomfort with the topic, as well as family and cultural dynamics.  The Stanford Letter Advance Directive (LAD) is a simple tool written at a fifth grade reading level in eight different languages [...]

Background: Advance care planning is nationally recognized as important for honoring patient wishes at the end of life. Despite this widespread recognition, many patients lack advance care planning and spend their last days in ways not concordant with their values. Moreover, traditional advance directives may provide only a partial context for patients’ belief systems relevant [...]

Background: Hospitalists commonly discuss advance care planning (ACP), which supports patients in understanding and expressing their values for medical care during serious illness. The coronavirus disease of 2019 (COVID-19) pandemic has increased the urgency of these conversations, especially for patients with older age, comorbidities, or an otherwise high risk for complications such as ICU admission, [...]

Background: Hospitalists often care for patients with serious illness and commonly review and discuss advance care planning (ACP). Documented ACP conversations can be difficult to access in the electronic health record (EHR) due to the lack of a centralized location for ACP documentation and individual clinician practice variation leading to ACP documentation existing in multiple [...]

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 planning should begin at the time of admission and involve preparing patients for the transition out of the hospital. Unfortunately, many hospitalized patients disagree with their provider about their discharge plan, including what needs to be accomplished in the hospital or the dismissal’s timing and location. When patients and their providers do not [...]

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 [...]