Background: In 2010, the Patient Protection and Affordable Care Act (ACA) aimed to enhance health insurance access through subsidies and Medicaid expansion. The expansion was not adopted by all states, leading to variable coverage. The Centers for Medicare & Medicaid Services (CMS) releases a 3-year running average of 30-day risk-standardized mortality rates for Medicare patients [...]

Background: Facilitating safe transitions of care is a common concern for the discharging hospitalist. Telephone calls are the most common method of contact for post-discharge outreach. These are labor-intensive and therefore limited in scope. To better support patients after hospital discharge, we designed and implemented a 30-day automated texting program. In a pilot study, this [...]

Background: Hospital readmissions are frequent and can represent low-quality, high-cost care. Timely post-hospital follow-up has been described as an important element of high-quality transitions of care and readmissions prevention (1-3), yet exactly what type of follow-up is most successful is unclear. We sought to understand the relationship between timing, hospital follow-up visit provider specialty and [...]

Background: The traditional role of hospitalists is to provide care to patients hospitalized with acute medical conditions. Over the past few years, this has evolved to improve care transitions and stewardship of hospital resources. Many hospitals may embed hospitalists in the Emergency Department (ED) to improve patient flow into the hospital; however, there are sparse [...]

Background: In 2010, the Patient Protection and Affordable Care Act (ACA) aimed to enhance health insurance access through subsidies and Medicaid expansion. The expansion was not adopted by all states, leading to variable coverage. The Centers for Medicare & Medicaid Services (CMS) releases a 3-year running average of 30-day risk-standardized mortality rates for Medicare patients [...]

Background: Facilitating safe transitions of care is a common concern for the discharging hospitalist. Telephone calls are the most common method of contact for post-discharge outreach. These are labor-intensive and therefore limited in scope. To better support patients after hospital discharge, we designed and implemented a 30-day automated texting program. In a pilot study, this [...]

Background: Hospital readmissions are frequent and can represent low-quality, high-cost care. Timely post-hospital follow-up has been described as an important element of high-quality transitions of care and readmissions prevention (1-3), yet exactly what type of follow-up is most successful is unclear. We sought to understand the relationship between timing, hospital follow-up visit provider specialty and [...]

Background: The traditional role of hospitalists is to provide care to patients hospitalized with acute medical conditions. Over the past few years, this has evolved to improve care transitions and stewardship of hospital resources. Many hospitals may embed hospitalists in the Emergency Department (ED) to improve patient flow into the hospital; however, there are sparse [...]

Background: Ambulatory care sensitive conditions (ACSCs) are a set of diagnoses that if not recognized and addressed properly in the ambulatory setting can lead to preventable hospitalizations. People experiencing homelessness (PEH) often have barriers to access of ambulatory care services and chronic disease self-management. These place them at high risk for having ACSCs, and contribute [...]

Background: Nationwide, hospitals are experiencing high patient volumes, attributed to medical complexity, hospital length of stay, and hospital readmissions, among other factors. In this context, hospitalists’ roles have been expanding to optimize care during and following hospitalization. Post-discharge care is typically managed by primary care providers, and there is sparse information on programs that leverage [...]