Transitions of Care

“Getting Ahold of a Physician Is Kind of a Fruitless Effort…we Don’t Get Call Backs Frequently”: Home Health Care Nurse Perspectives on Care Coordination for Recently Discharged Patients

Background: In 2012, nearly one-third of older adults (>65 years) with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between healthcare settings is frequently inadequate. We sought [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on “Getting Ahold of a Physician Is Kind of a Fruitless Effort…we Don’t Get Call Backs Frequently”: Home Health Care Nurse Perspectives on Care Coordination for Recently Discharged Patients

A National Assessment of Shift Handoff Characteristics and Their Association with Program Director Satisfaction and Hospitalized Patient Experience Scores

Background: Inpatient handoffs have been recognized as a vulnerable time during a patient’s hospitalization and are widely associated with adverse events and near misses. A variety of strategies have been implemented in order to improve [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on A National Assessment of Shift Handoff Characteristics and Their Association with Program Director Satisfaction and Hospitalized Patient Experience Scores

Against Our Advice: Provider Perspectives on Against Medical Advice Discharges at a County Hospital

Background: Against medical advice (AMA) discharges are often emotionally charged for healthcare providers. Complicated capacity assessments, confusion regarding legal and ethical obligations to patients, and limited resources may strain providers. This cross-sectional survey study explored [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Against Our Advice: Provider Perspectives on Against Medical Advice Discharges at a County Hospital

Are Hospitalized Patients with Hematuria Appropriately Cared for After Hospital Discharge?

Background: High-risk patients with hematuria often warrant an outpatient evaluation for bladder cancer; however the presence of microscopic hematuria may often be missed by primary care physicians after hospital discharge. Whether outpatient physician’s routinely follow-up [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Are Hospitalized Patients with Hematuria Appropriately Cared for After Hospital Discharge?

Are We on the Same Team? Interprofessional Perceptions of Discharge Delay Causes and Occurrence Frequency

Background: Unintentional discharge delays account for up to 20% of total patient hospital days. Previous studies identified bed availability, scheduling logistics for studies, and poor communication as causes of delay factors. Although discharge requires a [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Are We on the Same Team? Interprofessional Perceptions of Discharge Delay Causes and Occurrence Frequency

Association of Health Literacy and Social Support with Readmission Risk

Background: The period following hospital discharge is a vulnerable time for patients when increased self-care requirements are common. Low levels of health literacy and social support are thought to contribute to poor post-discharge outcomes. However, [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Association of Health Literacy and Social Support with Readmission Risk

Association of Hospital Admission Service Structure with Early Transfer to Critical Care, Hospital Readmission, and Length of Stay

Background: Hospital medical groups use various staffing models which systematically affect care continuity during the admission process. Our service changed models of care from a "general model", where hospitalists who perform hospital rounds and discharges [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Finalist, Research Abstracts, Transitions of Care|Comments Off on Association of Hospital Admission Service Structure with Early Transfer to Critical Care, Hospital Readmission, and Length of Stay

Blind Sided: Missing Poor Visual Acuity and Decreased Self-Efficacy in Hospitalized Patients with Diabetes

Background: One in five hospitalized patients has diabetes. Despite guideline recommendations for regular outpatient vision care, studies show gaps in outpatient vision assessments. The hospital setting may be an opportunity to identify patients with diabetes [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Finalist, Research Abstracts, Transitions of Care|Comments Off on Blind Sided: Missing Poor Visual Acuity and Decreased Self-Efficacy in Hospitalized Patients with Diabetes

Bridges to Care: Assessing the Effectiveness of a Behavioral Health Intervention in High Utilizers of Health Care

Background: Patients who are high utilizers of the health care system pose a significant burden to health care in the United States. These patients have higher rates of emergency department (ED) use, hospital readmission and [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Bridges to Care: Assessing the Effectiveness of a Behavioral Health Intervention in High Utilizers of Health Care

Discharges Against Medical Advice at a County Hospital: Who Is Leaving and Why?

Background: The principle that patients have the right to make choices about their healthcare, including the decision to leave the hospital against the advice of the medical staff, is a foundation of medical ethics.  Consistently, studies have found disproportionately higher rates of [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Discharges Against Medical Advice at a County Hospital: Who Is Leaving and Why?

Effect of a Web-Based Handoff Tool and Provider Training on Preventable Adverse Events

Background: Failures in communication among healthcare personnel are known threats to patient safety. Communication is particularly vulnerable to error when patient care responsibility is transferred from one provider to another (i.e., handoff). In this study [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Effect of a Web-Based Handoff Tool and Provider Training on Preventable Adverse Events

Effects of a Multi-Faceted Intervention to Improve Care Transitions Within a Pioneer Accountable Care Organization

Background: Transitions from hospitals to the ambulatory setting are high risk periods for patients. The advent of the Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) provide an opportunity for true collaboration in which [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Effects of a Multi-Faceted Intervention to Improve Care Transitions Within a Pioneer Accountable Care Organization

Evaluation of Patient Characteristics Associated with Duration of Discharge Services

Background: The Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service provided to the patient by his/her attending physician on the day of discharge. The two [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Evaluation of Patient Characteristics Associated with Duration of Discharge Services

Evaluation of the Yale New Haven Readmission Risk Score for Pneumonia in a General Hospital Population

Background: Pneumonia readmission rates are publicly reported and included as quality indicators in Medicare Value-Based Purchasing programs. The Yale New Haven Readmission Risk Score (YNHRRS) for Pneumonia is a tool that uses 25 variables including [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Evaluation of the Yale New Haven Readmission Risk Score for Pneumonia in a General Hospital Population

Helping Housestaff with Handoffs: Impact of Direct Observation and a Novel Handoff Tool on Resident General Medicine Team Handoff Performance

Background: Day-to-night inpatient handoff is a high-risk moment, with potential for miscommunication. A novel handoff program recently reduced medical errors and preventable adverse events. Historically, handoffs performed by Internal Medicine residents at our institution were [...]

By | 2016-02-01T08:00:34+00:00 February 1st, 2016|Research Abstracts, Transitions of Care|Comments Off on Helping Housestaff with Handoffs: Impact of Direct Observation and a Novel Handoff Tool on Resident General Medicine Team Handoff Performance