Background: Healthcare institutions have chronic bed shortages and a medically and socially complex patient population that makes optimal management of post-discharge care especially important. Effective and timely follow up post-hospitalization can improve clinical outcomes by delivering transitional care when patients are the most vulnerable. We developed a multimodal design that delivers education to patients and [...]

Background: Successful discharge practices and avoidance of readmission requires attention to social needs and care coordination with outpatient care providers. While national programs have attempted to identify interventions within the care continuum to prevent readmission, these programs rarely involve inpatient hospitalists. While robust requirements for certain care transitions processes such as medication reconciliation and discharge [...]

Background: Timeliness in transitional care improves clinical outcomes by delivering medical care at the most vulnerable post-hospitalization time. Primary care access to in-network and out-of-network patients’ post-hospitalization has been a challenge, especially to sicker patients with high risk of readmissions. Our institution Post-Discharge Clinic bridges this need by developing processes that will improve timely transitional [...]

Background: Timely, effective follow-up after hospital discharge can improve the efficiency and outcomes of care by increasing hospital throughput and decreasing readmissions and other adverse events after discharge. The University of Chicago Medical Center (UCMC) has chronic bed shortages and a medically and socially complex patient population that makes optimal management of post-discharge care especially [...]

Background: Our healthcare institution serves a large low-income, minority, and historically underserved population. The shortage of primary care physicians (PCPs) in our city and the high complexity of patients that are cared for by our organization is a challenge. Patients are in need of transitional care our institution and need help to connect to other [...]