Background: Automated bidirectional text messaging has emerged as a compelling strategy to facilitate communication between patients and the health system after hospital discharge. Understanding the unique ways in which patients interact with these messaging programs can inform future efforts to tailor their design to individual patient styles and needs. The aim of this study was [...]

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 [...]

Background: Discharge planning is an important component of safe and efficient hospital care. While standardization of these practices can be useful, adopting general approaches may overlook important nuance for unique patient populations. In particular, we are interested in how patients who live in a baseline unsafe situation conceptualize a “safe” discharge plan. Thus, our study [...]

Background: Inter-hospital transfer (IHT) refers to the movement of patients between acute care hospitals and is a routine practice within healthcare systems. The process, however, remains unstandardized, resulting in variability in how patients are identified, managed, and transferred, as well as in patient outcomes, safety, and associated costs. While IHT typically provides specialized care unavailable [...]

Background: Michigan Medicine’s Hospital Care at Home (HCAH) Program was designed to provide eligible patients living in Southeast Michigan hospital level care from their own homes. Since the advent of the CMS Hospital at Home Waiver in Nov 2020, 93% of HCAH programs have been in urban locations, with prominent programs in cities such as [...]

Background: Interhospital transfers (IHT) for additional care are a necessary, if high-risk, part of the healthcare system. Return transfers, in which the patient is returned to the referring hospital once higher-level care is no longer needed, are also a part of the healthcare system but are even more varied and less systematized and studied within [...]

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 [...]

Background: Written discharge instructions improve patient understanding and self-management after hospitalization, and they are an evidence-based practice to improve patient understanding. However, over the past three decades, studies have shown that patients have poor understanding and routinely overestimate their understanding of provider recommendations, placing them at higher risk for adverse medication events and hospital readmissions. [...]

Background: Patients in Acute Medical care Units (AMUs) often encounter complex discharge processes due to rapid turnover and acute care demands. The Advanced Clinical Practice Nurse-led Discharge management and Education (ADIEU) program was developed to address these challenges and improve post-discharge outcomes. In this study, we aimed to evaluate the effectiveness of the ADIEU program [...]

Background: Unplanned readmissions in the U.S. healthcare system cost over $15 billion annually, a burden that increasingly impacts health systems as more patients transition to fully capitated models [1-2]. Despite evidence supporting the protective effect of post-hospitalization visits with primary care providers (PCPs), patient completion rates of these visits remain low [3-5]. Barriers include provider [...]