Prior studies have found suboptimal knowledge about post-acute care (PAC) among inpatient providers and poor communication at discharge that can lead to unsafe discharge transitions, but little is known about residents and the PAC transition. The aim of this study is to assess internal medicine residents’ ...
Improving hospital discharge processes and reducing adverse outcomes after hospital discharge to skilled nursing facilities (SNFs) are gaining national recognition. However, little is known about how the social-contextual factors of hospitals and their affiliated SNFs may influence the discharge process an...
To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization.
To derive and validate a model to predict a patient's probability of skilled nursing facility (SNF) discharge using data available from day 1 of hospitalization.
Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the “Transitions of Care” (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care tra...
To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff.
To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents.
Our study examines factors associated with patient-reported outcomes in functioning among Medicare beneficiaries who reported receiving rehabilitation services in a nursing home or inpatient (ie, hospital or rehabilitation facility) setting in the prior year.