Background: Communication between hospital and outpatient clinicians is a key component to successful care transitions for older adults, yet this communication is frequently lacking. In addition, residents in academic medical centers are not routinely provided with feedback about post-discharge outcomes or opportunities for improvement. Purpose: To implement weekly video conferences that utilize the electronic medical [...]

Background: “Hospital at Home” (HaH) models of care have existed for over 20 years in the U.S. Demand for healthcare value, advances in relevant technologies, and the ongoing global pandemic have driven renewed attention to HaH models, by way of policy-based and academic pilot programs – and even commercialization attempts. Where studied, these models have [...]

Background: The convergence of rising post-acute health care costs with incomparable outcomes havemade reform a priority resulting in the development of new models of care that often extend the scope of practice andjob duties among health professionals. In these new models, aimed to improve clinical and cost effectiveness of care,advance practice “transitionists” diagnose, triage, conservatively [...]

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: 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: “Hospital at Home” (HaH) models of care have existed for over 20 years in the U.S. More recently, HaH models have evolved to include transitional care solutions to improve patients’ post-acute outcomes. Meanwhile, services which were traditionally provided only in the inpatient setting, such as elective arthroplasty, have begun to shift to same-day and [...]

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 [...]

Background: Healthcare institutions face a narrow operating budget to provide patient care. Centers for Medicare and Medicaid Services (CMS) evaluate healthcare institutions based on efficiency, quality and customer experience–in other words: length of stay, readmission rate and patients’ perception of the care they received. The effectiveness of decreased readmission is based on multiple variables, and [...]

Background: Patients hospitalized with COVID-19 are at risk for clinical deterioration after discharge. Because of this concern, hospitals established home monitoring programs during the pandemic. This study sought to describe these programs among a sample of US academic medical centers. Methods: We conducted a voluntary survey of hospital medicine leaders who participate in the Hospital [...]