Transitions of Care

HM2016 Abstract Number: 350

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 [...]

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HM2016 Abstract Number: 349

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 [...]

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HM2016 Abstract Number: 348

R-Va-Marquis: Implementing Best Practices in Medication Reconciliation for Rural Veterans

Background: High-quality medication reconciliation is key to reducing medication errors during care transitions. This concept is of paramount importance to Veterans living in rural areas due to less access to clinical pharmacy services. We adapted [...]

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HM2016 Abstract Number: 346

Impact of Electronic Health Records Interoperability on Inter-Hospital Transfer Outcomes

Background:  As electronic health records (EHR) become ubiquitous, the impact on patient outcomes remains largely unknown.  One major communication barrier during patient transfers is the lack of interoperability between EHR systems.  Inter-hospital transfers involve transitioning [...]

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HM2016 Abstract Number: 344

Prehospital Communication and Clinical Decompensation Following Direct Hospital Admission

Background:  Direct hospital admissions from outside emergency departments and hospitals comprise a large proportion of admissions to tertiary medical centers. Clinical stability in these acutely ill patients can fluctuate, even during transport to a receiving [...]

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HM2016 Abstract Number: 343

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 [...]

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HM2016 Abstract Number: 342

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 [...]

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HM2016 Abstract Number: 341

Patients Vs Providers: Perspectives of 30-Day Hospital Readmissions

Background: Since the roll out of the Affordable Care Act in 2012 there has been an increased financial pressure to prevent 30-day hospital readmissions. Yet the readmissions rate has remained relatively unchanged despite myriad of [...]

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HM2016 Abstract Number: 340

Quantifying Post Hospital Syndrome: Sleeping Longer and Physically Stronger?

Background: “Post hospital” syndrome is a critical period after discharge when patients are at risk of functional decline and re-admission. Two factors implicated in the development of this syndrome are sleep disturbance and low physical [...]

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HM2016 Abstract Number: 339

Preventing Pain Crisis & Hospitalizations: Are Patients with Sickle Cell Anemia Prescribed Hydroxyurea When Appropriate?

Background: Hydroxyurea is an FDA approved medication for use in adults with sickle cell disease. Clinical guidelines, based on high quality evidence, recommend its use in all adults with sickle cell anemia and 3 or [...]

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HM2016 Abstract Number: 338

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 [...]

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HM2016 Abstract Number: 337

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 [...]

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HM2016 Abstract Number: 336

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 [...]

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HM2016 Abstract Number: 335

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 [...]

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HM2016 Abstract Number: 333

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 [...]

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HM2016 Abstract Number: 332

National Evaluation of Interhospital Transfers

Background: Care transitions expose hospitalized patients to risks of discontinuity of care. Although various forms of care transitions have been widely studied, little is known about inter-hospital transfers (IHT, the transfer of patients between acute [...]

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HM2016 Abstract Number: 331

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 [...]

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HM2016 Abstract Number: 330

Improving Nurse-Physician Communication Around Discharge Education: A Discharge Timeout

Background: Nurse-Physician communication around discharge ensures that essential information is conveyed to patients when they leave the hospital. Yet nurses and physicians report poor communication during this critical time. The aim of this study was [...]

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HM2016 Abstract Number: 326

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 [...]

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HM2016 Abstract Number: 324

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, [...]

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HM2016 Abstract Number: 322

“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 [...]

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HM2016 Abstract Number: 321

Results from a Multidisciplinary Transitions of Care Pilot for Medicine and Heart Failure Patients at High Risk of Readmission

Background: Patients who are at risk for readmissions and emergency department visits following hospital discharge frequently have multiple medical comorbidities and a history of multiple prior hospitalizations. Over the past five years, reducing hospital readmissions [...]

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HM2016 Abstract Number: 320

Patient Experience with Dishcarge Instructions in Post-Discharge Recovery

Background: The role of discharge instructions in post-discharge recovery remains unexplored.  We examined the role of discharge instructions in post-discharge care for patients undergoing colorectal surgery and report themes related to patient perceptions of discharge [...]

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HM2016 Abstract Number: 319

This Is What Is Stopping Me from Leaving the Hospital: Does Daily Feedback to Physicians of Patient-Reported Readiness for Discharge Improve Discharge?

Background: Improving patients’ readiness for discharge is an important aspect of care transitions. Eliciting barriers to discharge from patients and providing daily feedback to their physicians may provide an approach to identifying and addressing problems [...]

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HM2016 Abstract Number: 318

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 [...]

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HM2016 Abstract Number: 317

Improving Peer to Peer Handoff Process at Service Change

Background: Handoffs are a part of inpatient medical care and can lead to patient care errors and threats to their safety.  Incomplete care transitions during service changes are associated with uncertainty of patient care plans. [...]

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HM2016 Abstract Number: 315

Parental Concerns About Discharge Warrant Early Introduction of Discharge Education

Background: Accumulating literature promotes early discharge education and transparency about hospitalization goals and discharge criteria as a key element of effective care transitions. However, little is known about the prevalence or nature of parental concerns [...]

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HM2016 Abstract Number: 316

Parent and Caregiver Perceptions of Essential Discharage Information

Background:   There is increasing recognition that high quality transitions of care are essential to ensuring patient safety. While no universal standard has been identified, using available literature and data from provider surveys, Project Impact identified [...]

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HM2016 Abstract Number: 314

Parental Preferences for Discharge Education Support Individualization, Early Onset and Use of Teach-Back

Background: Discharge education initiated early and performed with teach-back has been shown to improve transition outcomes. However, little is known about parental discharge education preferences.  Our objective was to understand parental preferences regarding discharge education learning [...]

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HM2016 Abstract Number: 313

Hospitalists Are Essential in Improving Prescriptions of Nicotine Replacement Therapy Among Hospitalized Tobacco Users and at Discharge

Background: The role of a hospitalist in treating nicotine withdrawal using counseling and medications during hospitalization can improve cessation rates of tobacco users. Clinical decision support and drug-condition alerts within the electronic medical record prompt [...]

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HM2016 Abstract Number: 308

Prospective Validation of the “Hospital” Score to Predict Patients at High Risk of Unplanned Readmission

Background: In order to most efficiently improve transition of care, hospitals need to target intensive discharge interventions at those patients at high risk of unplanned readmission. The “HOSPITAL” score, derived previously in the US, is [...]

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HM2016 Abstract Number: 307

Modified Early Warning Score (Mews) in the Emergency Department and Its Association with Admission Disposition

Background: The Modified Early Warning Score (MEWS) was validated in 2001. In recent years hospitals across the US have implemented the MEWS as a Rapid Response Team activation trigger. In Geisinger Medical Center the MEWS [...]

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HM2016 Abstract Number: 305

Outcomes of a Post-Discharge Physician Home Visit Intervention to Reduce Hospital Readmissions for High-Risk Patients

Background: Healthcare organizations are currently devoting significant resources to efforts to reduce hospital readmission after discharge.  Multiple factors have been linked to readmission, including an absence of outpatient follow-up care, inadequate understanding of discharge instructions [...]

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HM2016 Abstract Number: 304

Improving Decision-Making and Outcomes in Transitions to Post-Acute Care Facilities

Background: The number of older adults discharged to post-acute care (PAC) facilities (such as skilled nursing facilities) after hospitalization is increasing rapidly, but their clinical course in PAC is uncertain.  More than 25% will be [...]

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HM2016 Abstract Number: 303

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 [...]

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HM2016 Abstract Number: 301

Incidental Pulmonary Nodules Found on Ct Abdominal Imaging: Prevalence and Inclusion in the Discharge Hospital Summary

Background: While CT imaging has become an invaluable tool for expedited medical evaluation, its use has been associated with an increasing number of incidental findings, the handling of which creates both medical and logistical challenges.  [...]

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