Background: Research on post-discharge outpatient care often focuses on single types of encounters, such as primary care in-person appointments or primary care phone calls. However, patients interact with the healthcare system following discharge using a range of communication methods. This study seeks to examine the role of different types of post-discharge encounters on unplanned hospital [...]

Background: Patients discharged against medical advice (AMA) have disproportionately high healthcare costs and increased morbidity, mortality, and hospital readmissions. While patient risk factors for discharge AMA are known, there is little data regarding providers’ practice patterns during AMA discharge, including provision of follow-up appointments. Similarly, the frequency of a documented discussion of the risks and [...]

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: To support patients after hospital discharge, we developed and implemented a 30-day automated text-messaging intervention. The program was piloted in a single practice in Philadelphia, and was associated with a significant reduction in 30 day readmission and utilization of acute care resources. However, we wanted to understand the timing and nature of patient needs [...]

Background: In a learning healthcare system, data collected as part of routine care is used to fuel innovation and improvement. Predictive models for post-discharge adverse events have relied on data that is available prior to hospital discharge. Post-discharge care (e.g. appointments, phone calls) can be collected from electronic health records and may impact patient risk [...]

Background: Congestive heart failure (CHF) is a major cause of mortality and morbidity among general population despite recent advancements in goal-directed therapies. The advent of mechanical circulatory devices, the increased availability and improvement in heart transplant techniques have improved some metrics; however, CHF patients continue to have multiple readmissions for acute exacerbations. The frequency of [...]

Background: Virtual care is becoming a fully realized modality of providing patient care (1, 2). In hospital medicine, the transition of care from inpatient to outpatient can be challenging to carry out efficiently and effectively while mitigating any preventable harm that may arise prior to a scheduled follow-up appointment with a primary care physician (PCP). [...]

Background: The period immediately following discharge from a hospital admission is a vulnerable time for patients. Preventable adverse outcomes occur here for various reasons: discontinuity between hospitalists and primary care physicians, changes to medication regimens, and complex discharge instructions [1]. Many of these precipitating factors can be avoided by effective exchange of health information and [...]

Background: Sepsis is a life-threatening condition involving organ dysfunction caused by a dysregulated response to infection [1]. Sepsis is the leading cause of 30-day unplanned readmissions nationwide [2]. At UF Health Shands Hospital, the 30-day readmission rate for sepsis patients is 17% compared to 13% for all adult patients. Of those readmitted for sepsis, 38% [...]

Background: Patients who complete a primary care provider (PCP) follow-up visit within 7 days of hospital discharge have lower odds of 14-day readmission (p=0.002) OR= 0.45 (95% CI: 0.27 – 0.73) compared to patients who do not at our academic institution. However, only 44% of patients complete this visit. Patients who were scheduled with their [...]