Background: The Center for Medicare and Medicaid Services (CMS) instituted the Readmissions Reduction Program to incentivize improvements in care transitions for patients with several common and serious illnesses, including heart failure, acute myocardial infarction, pneumonia, and more recently COPD exacerbations. The HOSPITAL score has been shown to accurately identify medical patients at high-risk for 30-day [...]

Background: Remote patient monitoring (RPM) is a promising new tool to monitor patients who have historically required observation visits in a hospital, or would have remained hospitalized longer if initiated at hospital discharge, and was widely used in the COVID-19 pandemic. We report the outcomes of hospital admission and urgent/emergent care service utilization in a [...]

Background: The Center for Medicare and Medicaid Services (CMS) instituted the Readmissions Reduction Program to incentivize improvements in care transitions for patients with several common and serious illnesses, including heart failure, acute myocardial infarction, pneumonia, and more recently COPD exacerbations. The HOSPITAL score has been shown to accurately identify medical patients at high-risk for 30-day [...]

Background: Remote patient monitoring (RPM) is a promising new tool to monitor patients who have historically required observation visits in a hospital, or would have remained hospitalized longer if initiated at hospital discharge, and was widely used in the COVID-19 pandemic. We report the outcomes of hospital admission and urgent/emergent care service utilization in a [...]

Background: The discharge process is complex and high-risk. Clear and accurate communication between the physician or Advanced Practice Provider (providers), nurse, and patient are essential to ensure a safe and effective transition of care. Upon literature review, there have not been studies looking at interprofessional communication during the discharge process. Also, our institution (a large [...]

Background: With the advancement of technology and the provision of critical care, more critically ill patients are surviving the medical intensive care unit (ICU). Upon transfer to the general wards patients continue to face complex and ongoing medical issues that increase their risk of morbidity and mortality. This study aimed to determine patient characteristics as [...]

Background: After discharge from an acute care hospitalization, cancer patients may choose to pursue rehabilitative care in a skilled nursing facility (SNF). Our objective was to examine receipt of anti-cancer therapy, death, readmission, and hospice use of cancer patients who discharge to a SNF compared to those who discharge home or home with home health [...]

Background: With the advancement of technology and medical care, more critically ill patients are surviving the medical intensive care unit (ICU) and are transferred to the general wards, where they spend the majority of their hospitalization. While there are guidelines that address common complications in the ICU (delirium and functional decline), once patients are transferred [...]

Background: Care of the pediatric patient does not end after the family exits the hospital doors. Post-discharge issues can lead to significant consternation for families, unnecessary risk to the patient, and re-utilization of healthcare resources. Despite careful preparation for transfer of care to the primary care physician (PCP), some post-discharge issues are unanticipated and lead [...]

Background: Frequent readmissions pose a challenge to hospitals across the country. They are associated with increasing healthcare costs and display a failure to effectively care for certain groups of patients. The Centers for Medicare and Medicaid Services (CMS) apply a penalty towards hospitals with higher than expected 30-days readmission rates. In response, hospitals have implemented [...]