Transitions of Care

A Framework for Improving Safety, Efficiency, and Education in Holdover Signout

Background: Multiple tools have been developed to improve the quality of signout from daytime clinicians to night covering clinicians. However, despite the frequency of holdover signout (new overnight admissions whose care is transferred to a [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on A Framework for Improving Safety, Efficiency, and Education in Holdover Signout

A Multidisciplinary Care Coordination and Continuity Intervention for High Utilizers on a Hospitalist Service

Background: Patients recurrently admitted to the hospital account for a disproportionate percentage of hospital costs and frequently experience fragmentation of care and poor health outcomes. On our hospitalist service at a large academic medical center, [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on A Multidisciplinary Care Coordination and Continuity Intervention for High Utilizers on a Hospitalist Service

Acute and Post-Acute Care Collaboration: Front Line Approach to Reduce Readmissions

Background: Patients discharged to post-acute care facilities are at higher risk for re-admissions compared to those discharged home. Mount Sinai Hospital (MSH) discharges a significant number of patients to Terence Cardinal Cooke Health Care Center (TCC), [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Acute and Post-Acute Care Collaboration: Front Line Approach to Reduce Readmissions

Assessing the Feasibilty and Implementation of a Bedside Service Handoff on an Academic Hospitalist Service: A Physicians Perspective

Background: Inpatient service handoffs have been recognized as a vulnerable time during a patients’ hospitalization. Prior studies have suggested the need for more systematic, team-based, and patient-centered handoff models. We hypothesized that performing the service [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Assessing the Feasibilty and Implementation of a Bedside Service Handoff on an Academic Hospitalist Service: A Physicians Perspective

Improving Medication Safety Through a New Multidisciplinary Approach to Medicine Reconciliation at an Urban Safety Net Academic Hospital

Background: Studies have shown that care transitions represent times of great risk, especially to vulnerable patients; medication reconciliation is a major component of ensuring safe care transitions. Yet, challenges exist to obtaining a best possible [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Improving Medication Safety Through a New Multidisciplinary Approach to Medicine Reconciliation at an Urban Safety Net Academic Hospital

Integration of Observation Medicine in Internal Medicine Training Through a Milestone Based Hospitalist Rotation

Background: Observation services continue are a growing part of U.S. healthcare, with over 90% of surveyed hospitalist groups providing observation care. Despite observation services growing at teaching hospitals, few residents receive structured training in this [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Integration of Observation Medicine in Internal Medicine Training Through a Milestone Based Hospitalist Rotation

Intensive Follow Up After Palliative Care Consultations to Reduce Readmissions

Background: Kaiser Permanente Roseville Medical Center is a 340 bed facility in Northern California.  Reducing readmissions has been a focus, and the current observed over expected rate is 0.77.  Starting from this relatively low readmission [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Finalist, Innovations Abstracts, Transitions of Care|Comments Off on Intensive Follow Up After Palliative Care Consultations to Reduce Readmissions

Novel Pharmacist-Managed Rivaroxaban Clinic for Outpatient Treatment of Venous Thromboembolism

Background: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), affects one to two per one thousand persons annually in the US. Treatment of VTE consists of anticoagulation therapy, and evidence supports [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Finalist, Innovations Abstracts, Transitions of Care|Comments Off on Novel Pharmacist-Managed Rivaroxaban Clinic for Outpatient Treatment of Venous Thromboembolism

Pilot of an Embedded Discharge Scheduler for a Patient-Centered Discharge Process

Background: At our medical center, there are 14,716 discharges annually from the general medicine services. Post discharge appointments are made by residents, nurse practitioners, and hospitalists. In a baseline survey, clinicians identified logistical barriers to [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Pilot of an Embedded Discharge Scheduler for a Patient-Centered Discharge Process

Resident Satisfaction After Implementation of the I-Pass Handoff Bundle

Background: The ACGME duty hour standards have led to an increased frequency of transitions of care, necessitating a need to improve communication skills to prevent adverse events related to handoffs. The ACGME also requires residency [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Resident Satisfaction After Implementation of the I-Pass Handoff Bundle

Stepwise Quality Improvement (Qi) in Writing Discharge Summaries to Achieve Efficient and Effective Care Transitions

Background: Poor communication among health providers during transitions of care (TOC) between inpatient and outpatient settings is being increasingly recognized as responsible for subpar health outcomes, wasteful healthcare spending and low patient satisfaction. Such poor [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on Stepwise Quality Improvement (Qi) in Writing Discharge Summaries to Achieve Efficient and Effective Care Transitions

The Rockfish Pilot: A Web-Based Application to Assist Patient Transitions from Hospital to Snf

Background: The current process of transitioning to a skilled nursing facility (SNF) is non-transparent and inefficient. For patients and caregivers, the process is stressful and confusing. For the providers and the hospital, it could result [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Innovations Abstracts, Transitions of Care|Comments Off on The Rockfish Pilot: A Web-Based Application to Assist Patient Transitions from Hospital to Snf