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Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59:901-906.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

The Hospital at Homesm program provides hospital-level care (including daily physician and nurse visits, diagnostic testing, treatment, and other support) in a patient's home as a full substitute for acute hospital care for selected conditions that are common among seniors. Studies have shown that the Hospital at Home program results in lower length of stay, costs, readmission rates, and complications than does traditional inpatient care, and surveys indicate higher levels of patient and family member satisfaction than with traditional care.

Herges JR, Garrison GM, Mara KC, et al. J Am Pharm Assoc (2003). 2020;61:68-73.
The goal of medication reconciliation is to prevent adverse events by identifying unintended medication discrepancies during transitions of care. This retrospective cohort evaluated the impact of attending a pharmacist-clinician collaborative (PCC) visit after hospital discharge with their medication containers on risk of 30-day readmission. Among adult patients on at least 10 total medications, findings indicate no significant difference in 30-day hospital readmission risk between patients presenting to a PCC visit with their medication containers compared with patients who did not. However, when patients did present to their PCC visit with medication containers, pharmacists identified more medication discrepancies and resolved more medication-related issues.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.