Background: Older adults are commonly discharged to skilled nursing facilities (SNFs) after hospitalization. It is not known how patients anticipate SNF discharges and what they prioritize. The aims of this study are to explore what matters most to older adults during their hospital to SNF care transition. Methods: We conducted a grounded theory qualitative study. [...]

Background: Over 5 million hospital-to-skilled nursing facility (SNF) transitions occur annually. Of these patients, 20% are readmitted within 30 days, and 25% of those readmissions are deemed preventable. While effective communication between the inpatient clinician and the accepting SNF clinician has been shown to improve re-hospitalization rates, few studies have examined clinician confidence or competence [...]

Background: Timeliness in transitional care improves clinical outcomes by delivering medical care at the most vulnerable post-hospitalization time. Primary care access to in-network and out-of-network patients’ post-hospitalization has been a challenge, especially to sicker patients with high risk of readmissions. Our institution Post-Discharge Clinic bridges this need by developing processes that will improve timely transitional [...]

Background: Hospital discharge is a complex process for patients, caregivers, and providers. A patients’ understanding of new diagnoses, medications, and appointments improves the capacity for self-care and post-discharge outcomes. A new “Team Discharge” initiative was piloted to improve patients’ understanding of the discharge plan through patient-centeredness and interdisciplinary communication during the critical transition from hospital [...]

Background: Hospital discharge is a vulnerable moment in healthcare delivery that impacts patient safety and experience. Improving this care transition necessitates a focus on the most error-prone and potentially hazardous parts of the process, including discharge logistics (e.g., transportation), medication safety, follow-up plans, and contingency planning. Many interventions have been investigated to improve discharge processes; [...]

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: Inter-hospital transfer (IHT), defined as the transfer of patients between acute care facilities, is a common practice. Despite assumptions that IHT is done to provide patients with necessary specialized care, the factors which drive patient transfer are highly variable in ways that are not fully explained by differences in patients or hospitals. As such, [...]

Background: Hospital bed capacity is limited across the nation due to increased demand and staffing shortages. Capacity shortages result in hospital diversion and therefore impact Emergency Department (ED) length of stay and ED medical boarding. A large tertiary hospital typically serves as the referral hub for many smaller hospitals in the region, and optimizing bed [...]

Background: In 2006, the Institute of Medicine issued a report on the state of emergency care, which identified overcrowding and patient boarding as major concerns. Subsequent research has confirmed that boarding in the emergency department (ED) leads to adverse events including medication errors, higher mortality, and lower patient satisfaction. In answer to this, hospitalist groups [...]

Background: Hospitals globally have been facing unprecedented challenges with patient throughput and capacity, especially in the aftermath of the COVID-19 pandemic. Efficient discharge processes are integral to improving bed availability and mitigating the negative outcomes associated with patient boarding in emergency departments Purpose: This study evaluates the efficacy of an early morning huddle approach in [...]