Background: Hospital readmissions are an important marker of healthcare quality, reflecting worse patient outcomes and resulting in millions of dollars of penalties annually. Medication nonadherence is an important driver of hospital readmissions, with one significant factor being difficulty obtaining medications after discharge. The difficulty could be due to copays, availability, or transportation to a local [...]

Background: Heart failure (HF) hospital readmissions are a leading cause of US 30-day hospital readmissions. Factors related to clinical complexity and unmet social needs are among the key drivers associated with HF negative clinical outcomes. Digital platforms have shown promise in improving HF outcomes but limitations like patient lack of familiarity with technology and unmet [...]

Background: Heart failure (HF) is a major public health concern that affects over 5 million adults in the US. HF is among the most common reasons for hospital admissions and presents a considerable cost burden to the medical system. Patients are stabilized and carefully monitored at the hospital but often go home without adequate follow-up [...]

Case Presentation: A 76 year-old male with a history of diverticulitis, T2DM, HTN, persistent atrial fibrillation and compensated alcoholic cirrhosis presented for recurrent gastrointestinal bleeding (GIB). He initially presented to an outside hospital six months prior for shortness of breath and found to be anemic requiring 4 units of packed red blood cells (PRBCs). Since [...]

Background: Effective communication at hospital discharge between inpatient and outpatient providers is critical to improving transitions of care and reducing hospital readmissions. A key part of transitions communication is the hospital discharge summary (DCS). Prior studies show that DCSs are often not available to primary care providers (PCPs) at the time of hospital follow-up and [...]

Background: Hospital readmission is detrimental and is often a consequence of patient vulnerabilities, social factors and inadequate health system safeguards. The current 30-day readmission rate for Internal Medicine patients at the University Hospital is 13.43%. Historically, little has been known about patients’ perspective on factors that contributed to their readmission. Previous studies have shown that [...]