National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- Adverse Events (1)
- Behavioral Health (1)
- Cardiovascular Conditions (4)
- Care Coordination (2)
- Caregiving (1)
- Care Management (1)
- Comparative Effectiveness (1)
- Depression (1)
- Education: Patient and Caregiver (1)
- Elderly (4)
- Electronic Health Records (EHRs) (2)
- Healthcare Delivery (2)
- Healthcare Utilization (1)
- Health Information Technology (HIT) (3)
- Heart Disease and Health (3)
- Home Healthcare (4)
- Hospital Discharge (9)
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- (-) Hospital Readmissions (23)
- Hospitals (6)
- Human Immunodeficiency Virus (HIV) (1)
- Medicare (1)
- Nursing Homes (4)
- Patient-Centered Healthcare (1)
- Patient-Centered Outcomes Research (1)
- Patient Safety (1)
- Primary Care (1)
- Primary Care: Models of Care (1)
- Provider: Pharmacist (1)
- Quality Improvement (1)
- Quality Indicators (QIs) (1)
- Quality Measures (1)
- Quality of Care (1)
- Quality of Life (1)
- Respiratory Conditions (1)
- Risk (1)
- Surgery (1)
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- (-) Transitions of Care (23)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 23 of 23 Research Studies DisplayedSquires A, Engel P, Ma C
Continuity of care versus language concordance as an intervention to reduce hospital readmissions from home health care.
The purpose of this study was to examine the relative effectiveness of continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. Participants included over 22,000 non-English-speaking patients from the New York City area who were admitted to their home health site following hospital discharge. Findings revealed that high continuity of care and high language concordance significantly decreased readmissions, along with high continuity of care and low language concordance; low continuity of care and high language concordance did not significantly impact readmissions. The authors concluded that enhancing continuity of care for those with language barriers the US home health system may help to address disparities and reduce hospital readmission rates.
AHRQ-funded; HS023593.
Citation: Squires A, Engel P, Ma C .
Continuity of care versus language concordance as an intervention to reduce hospital readmissions from home health care.
Med Care 2023 Sep; 61(9):605-10. doi: 10.1097/mlr.0000000000001884..
Keywords: Hospital Readmissions, Transitions of Care, Home Healthcare
Saxena FE, Bierman AS, Glazier RH
AHRQ Author: Bierman AS
Association of Early Physician Follow-up With Readmission Among Patients Hospitalized for Acute Myocardial Infarction, Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease.
Investigators assessed whether hospitalized patients with early physician follow-up after discharge had lower rates of overall and condition-specific readmissions within 30 days and 90 days of discharge. Studying adults in Ontario, Canada, with first admission for acute myocardial infarction, congestive heart failure, or chronic obstructive pulmonary disease, the findings suggested that early follow-up in conjunction with a comprehensive transitional care strategy for hospitalized patients with medically complex conditions coupled with ongoing effective chronic disease management may be associated with reduced 90-day readmissions.
AHRQ-authored.
Citation: Saxena FE, Bierman AS, Glazier RH .
Association of Early Physician Follow-up With Readmission Among Patients Hospitalized for Acute Myocardial Infarction, Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease.
JAMA Netw Open 2022 Jul;5(7):e2222056. doi: 10.1001/jamanetworkopen.2022.22056..
Keywords: Hospital Readmissions, Hospitalization, Cardiovascular Conditions, Respiratory Conditions, Transitions of Care
Mitchell SE, Reichert M, Howard JM
Reducing readmission of hospitalized patients with depressive symptoms: a randomized trial.
The purpose of this randomized controlled trial study was to assess whether post-discharge depression treatment will benefit hospitalized patients by reducing readmissions. Participants included hospitalized patients with a patient health questionnaire-9 score of 10 or higher. The researchers delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention. The study found that at 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission or reutilization. The intention-to-treat analysis also showed no differences at 90 days in readmission or reutilization. In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions. The study concluded that unplanned hospital use can be decreased with post-discharge treatment of depression and support for care transition.
AHRQ-funded; HS019700.
Citation: Mitchell SE, Reichert M, Howard JM .
Reducing readmission of hospitalized patients with depressive symptoms: a randomized trial.
Ann Fam Med 2022 May-Jun;20(3):246-54. doi: 10.1370/afm.2801..
Keywords: Depression, Behavioral Health, Hospital Readmissions, Hospital Discharge, Transitions of Care
Manges KA, Ayele R, Leonard C
Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach.
This study’s objective was to explore differences between low- and high-performing hospitals and skilled nursing facilities (SNFs) pairs and postacute care outcomes. The authors used flow maps and thematic analysis to describe the process of hospitals discharging patients to SNFs and to identify differences in subprocesses used by high-performing and low-performing hospitals. Hospitals were classified based on their 30-day readmission rates from SNFs. The final sample included 148 hours of observations with 30 clinicians across four hospitals and five corresponding SNFs. High-performing sites differed in each stage from low-performing sites by focusing on 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to an SNF as an iterative team-based process and 3) anticipating barriers with knowledge of transitional and SNF care processes.
AHRQ-funded; HS026116.
Citation: Manges KA, Ayele R, Leonard C .
Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach.
BMJ Qual Saf 2021 Aug;30(8):648-57. doi: 10.1136/bmjqs-2020-011204..
Keywords: Transitions of Care, Hospitals, Nursing Homes, Hospital Readmissions, Hospital Discharge
Misra-Hebert AD, Rothberg MB, Fox J
Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.
This retrospective cohort study assessed the association of home visits by advanced practice registered nurses (APRNs) and paramedics with healthcare utilization and mortality of patients released home after hospital discharge The authors looked at adult medical patients discharged to home from November 2017-September 2019. They assessed outcomes for home visit vs. matched comparison patients at 30, 90, and 180 days, including hospital admission, emergency department (ED) use, and death using two phases. Phase 1 was defined as APRN or paramedic visits assigned by geographic location and Phase 2 defined as APRN and paramedic visit teams assigned to patients. They also compared patients who declined home visits with those accepting them. Phase 1 outcomes showed no differences in readmissions, ED visits, or death at 30,90, and 180 days. Phase 2 showed patients who had home visits had fewer 30-day readmissions and no differences in other outcomes. Patients who accepted home visits had lower odds of readmission compared to patients who declined. Forty-four interviews were also conducted, and themes of Medication Understanding, Knowledge Gap after Discharge, Patient Medical Complexity, Social Context, and Patient Engagement/Need for Reassurance emerged.
AHRQ-funded; HS024128.
Citation: Misra-Hebert AD, Rothberg MB, Fox J .
Healthcare utilization and patient and provider experience with a home visit program for patients discharged from the hospital at high risk for readmission.
Healthc 2021 Mar;9(1):100518. doi: 10.1016/j.hjdsi.2020.100518..
Keywords: Home Healthcare, Transitions of Care, Hospital Discharge, Hospital Readmissions
Saleh SN, Makam AN, Halm EA,
Can we predict early 7-day readmissions using a standard 30-day hospital readmission risk prediction model?
Despite focus on preventing 30-day readmissions, early readmissions (within 7 days of discharge) may be more preventable than later readmissions (8-30 days). In this study, the investigators assessed how well a previously validated 30-day EHR-based readmission model predicted 7-day readmissions and compared differences in strength of predictors. They suggested that improvements in predicting early 7-day readmissions will likely require new risk factors proximal to day of discharge.
AHRQ-funded; HS022418.
Citation: Saleh SN, Makam AN, Halm EA, .
Can we predict early 7-day readmissions using a standard 30-day hospital readmission risk prediction model?
BMC Med Inform Decis Mak 2020 Sep 15;20(1):227. doi: 10.1186/s12911-020-01248-1..
Keywords: Hospital Readmissions, Hospitals, Risk, Transitions of Care, Electronic Health Records (EHRs), Health Information Technology (HIT)
Weerahandi H, Bao H, Herrin J
Home health care after skilled nursing facility discharge following heart failure hospitalization.
Heart failure (HF) readmission rates have plateaued despite scrutiny of hospital discharge practices. Many HF patients are discharged to skilled nursing facility (SNF) after hospitalization before returning home. Home healthcare (HHC) services received during the additional transition from SNF to home may affect readmission risk. In this study, the investigators examined whether receipt of HHC affects readmission risk during the transition from SNF to home following HF hospitalization.
AHRQ-funded; HS022882.
Citation: Weerahandi H, Bao H, Herrin J .
Home health care after skilled nursing facility discharge following heart failure hospitalization.
J Am Geriatr Soc 2020 Jan;68(1):96-102. doi: 10.1111/jgs.16179..
Keywords: Home Healthcare, Nursing Homes, Heart Disease and Health, Cardiovascular Conditions, Hospitalization, Hospital Readmissions, Transitions of Care, Elderly
Saluja S, Hochman M, Bourgoin A
Primary care: the new frontier for reducing readmissions.
To date, efforts to reduce hospital readmissions have centered largely on hospitals. In a recently published environmental scan, the investigators examined the literature focusing on primary care-based efforts to reduce readmissions. They found that multi-component care transitions programs that are initiated early in the hospitalization and are part of broader primary care practice transformation appear most promising.
AHRQ-funded; 233201500019I.
Citation: Saluja S, Hochman M, Bourgoin A .
Primary care: the new frontier for reducing readmissions.
J Gen Intern Med 2019 Dec;34(12):2894-97. doi: 10.1007/s11606-019-05428-2.
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Keywords: Primary Care, Hospital Readmissions, Hospitals, Transitions of Care, Primary Care: Models of Care, Healthcare Delivery
Jones CD, Falvey J, Hess E
Predicting hospital readmissions from home healthcare in Medicare beneficiaries.
The authors used patient-level clinical variables to develop and validate a parsimonious model to predict hospital readmissions from home healthcare (HHC) in Medicare fee-for-service beneficiaries. They found that variables available to HHC clinicians at the first post-discharge HHC visit can predict readmission risk and inform care plans in HHC. They recommend that future analyses incorporating measures of social determinants of health, such as housing instability or social support, have the potential to enhance prediction of this outcome.
AHRQ-funded; HS024569.
Citation: Jones CD, Falvey J, Hess E .
Predicting hospital readmissions from home healthcare in Medicare beneficiaries.
J Am Geriatr Soc 2019 Dec;67(12):2505-10. doi: 10.1111/jgs.16153..
Keywords: Home Healthcare, Hospital Readmissions, Medicare, Elderly, Transitions of Care
Nijhawan AE, Higashi RT, Marks EG
Patient and provider perspectives on 30-day readmissions, preventability, and strategies for improving transitions of care for patients with HIV at a safety net hospital.
Researchers assessed perceived causes of 30-day hospital readmissions, factors associated with preventability, and strategies to reduce preventable readmissions and improve continuity of care for HIV-positive individuals. Using semi-structured interviews, they found that the 30-day metric should be adjusted for safety net institutions and patients with AIDS; that participants disagreed about preventability; and that various stakeholders proposed readmission reduction strategies that spanned the inpatient to outpatient care continuum. They then outlined multiple interventions which could substantially decrease hospital readmissions in this underserved population.
AHRQ-funded; HS022418.
Citation: Nijhawan AE, Higashi RT, Marks EG .
Patient and provider perspectives on 30-day readmissions, preventability, and strategies for improving transitions of care for patients with HIV at a safety net hospital.
J Int Assoc Provid AIDS Care 2019 Jan-Dec;18:2325958219827615. doi: 10.1177/2325958219827615..
Keywords: Human Immunodeficiency Virus (HIV), Transitions of Care, Hospital Readmissions, Hospitals
Gupta S, Zengul FD, Davlyatov GK
Reduction in hospitals' readmission rates: role of hospital-based skilled nursing facilities.
The purpose of this study was to examine the association between hospital-based skilled nursing facilities (HBSNFs) and hospitals' readmission rates. Data sources included the American Hospital Association Annual Survey, Area Health Resources Files, CMS Medicare cost reports and Hospital Compare. Results showed that the presence of HBSNFs was associated with lower readmission rates for acute myocardial infarction and pneumonia. Further, higher skilled nursing facilities to hospitals ratio were associated with lower readmission rates.
AHRQ-funded; HS023345.
Citation: Gupta S, Zengul FD, Davlyatov GK .
Reduction in hospitals' readmission rates: role of hospital-based skilled nursing facilities.
Inquiry 2019 Jan-Dec;56:46958018817994. doi: 10.1177/0046958018817994..
Keywords: Hospital Readmissions, Transitions of Care, Care Coordination, Hospitals, Quality Indicators (QIs), Quality Measures, Quality of Care
Jones CD, Anthony A, Klein MD
The effect of a pharmacist-led multidisciplinary transitions-of-care pilot for patients at high risk of readmission.
The purpose of this study was to evaluate the feasibility and effect of a pharmacist-led transitions-of-care (TOC) pilot targeted to patients at high risk of readmission on process measures, hospital readmissions, and emergency department visits. Results showed that a pharmacist-led TOC pilot demonstrated potential for reducing hospital readmissions. The intervention was time intensive and led to the creation of a TOC pharmacist role to implement medication-related transitional care.
AHRQ-funded; HS024569.
Citation: Jones CD, Anthony A, Klein MD .
The effect of a pharmacist-led multidisciplinary transitions-of-care pilot for patients at high risk of readmission.
J Am Pharm Assoc 2018 Sep - Oct;58(5):554-60. doi: 10.1016/j.japh.2018.05.008..
Keywords: Hospital Readmissions, Provider: Pharmacist, Transitions of Care
Balaban RB, Zhang F, Vialle-Valentin CE
Impact of a patient navigator program on hospital-based and outpatient utilization over 180 days in a safety-net health system.
The objective of this study was to determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period. The investigators concluded that a PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. The investigators suggest that their findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time peri
AHRQ-funded; HS020628.
Citation: Balaban RB, Zhang F, Vialle-Valentin CE .
Impact of a patient navigator program on hospital-based and outpatient utilization over 180 days in a safety-net health system.
J Gen Intern Med 2017 Sep;32(9):981-89. doi: 10.1007/s11606-017-4074-2..
Keywords: Care Management, Healthcare Delivery, Healthcare Utilization, Hospital Readmissions, Patient-Centered Healthcare, Transitions of Care
McHugh JP, Foster A, Mor V JP, Foster A, Mor V
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
This study used a concurrent mixed-methods approach to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal skilled nursing facilities (SNF) networks.
AHRQ-funded; HS023961.
Citation: McHugh JP, Foster A, Mor V JP, Foster A, Mor V .
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
Health Aff 2017 Sep;36(9):1591-98. doi: 10.1377/hlthaff.2017.0211..
Keywords: Care Coordination, Hospital Readmissions, Hospitals, Nursing Homes, Transitions of Care
Clark B, Baron K, Tynan-McKiernan K
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study.
The purpose of this paper was to understand the perspectives of clinicians working at skilled nursing facilities (SNFs) regarding factors contributing to readmissions. SNF clinicians identified a broad range of factors that contributed to readmissions. The investigators suggest that addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.
AHRQ-funded; HS023554.
Citation: Clark B, Baron K, Tynan-McKiernan K .
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study.
J Hosp Med 2017 Aug;12(8):632-38. doi: 10.12788/jhm.2785..
Keywords: Hospital Readmissions, Nursing Homes, Quality Improvement, Transitions of Care
Jones CE, Hollis RH, Wahl TS
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
The researchers performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery. Discharge planning programs reduced readmissions by 11.5 percent , 12.5 percent, and 23 percent . Patient education interventions reduced readmissions by 14 percent and 23.5 percent . Primary care follow-up reduced readmissions by 8.3 percent for patients after high-risk surgeries . Home visits reduced readmissions by 7.7 percent and 4 percent, respectively.
AHRQ-funded; HS013852.
Citation: Jones CE, Hollis RH, Wahl TS .
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
Am J Surg 2016 Aug;212(2):327-35. doi: 10.1016/j.amjsurg.2016.04.004.
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Keywords: Education: Patient and Caregiver, Hospital Discharge, Hospital Readmissions, Transitions of Care
Donovan JL, Kanaan AO, Gurwitz JH
A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes.
The authors investigated whether or not patients transferred from skilled nursing facilities to home may be at risk for adverse outcomes. They tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days. They concluded that older adults discharged from skilled nursing facilities are at high risk of adverse outcomes immediately following discharge.
AHRQ-funded; HS017817.
Citation: Donovan JL, Kanaan AO, Gurwitz JH .
A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes.
J Am Med Dir Assoc 2016 Apr;17(4):312-7. doi: 10.1016/j.jamda.2015.11.008.
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Keywords: Health Information Technology (HIT), Transitions of Care, Adverse Events, Elderly, Hospital Readmissions
Vora AN, Peterson ED, Hellkamp AS
Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients.
Many patients in the United States require transfer from one hospital to another for acute myocardial infarction (MI) care. How well these transferred-in patients are transitioned back to their local community is unknown. This study found that transferred-in patients with acute MI are less likely to have outpatient clinic follow-up within 30 days and more likely to be readmitted within the first 30 days post discharge compared with direct-arrival patients.
AHRQ-funded; HS021092.
Citation: Vora AN, Peterson ED, Hellkamp AS .
Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients.
Circ Cardiovasc Qual Outcomes 2016 Mar;9(2):109-16. doi: 10.1161/circoutcomes.115.002108.
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Keywords: Transitions of Care, Hospital Readmissions, Cardiovascular Conditions, Patient-Centered Outcomes Research, Hospital Discharge
Dharmarajan K, Chaudhry SI
New approaches to reduce readmissions in patients with heart failure.
The authors discuss a study by Ong and colleagues that presents the results of Better Effectiveness After Transition–Heart Failure (BEATHF), a randomized clinical trial of a combined telemonitoring and care transitions intervention to prevent readmission in patients with heart failure. The BEAT-HF intervention did not lower readmissions after hospitalization for heart failure.
AHRQ-funded; HS023554.
Citation: Dharmarajan K, Chaudhry SI .
New approaches to reduce readmissions in patients with heart failure.
JAMA Intern Med 2016 Mar;176(3):318-20. doi: 10.1001/jamainternmed.2015.7993.
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Keywords: Heart Disease and Health, Hospital Discharge, Hospital Readmissions, Quality of Life, Transitions of Care
Kansagara D, Chiovaro JC, Kagen D
So many options, where do we start? An overview of the care transitions literature.
The purpose of this paper is to summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. The authors found evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. They further found that transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations.
AHRQ-funded; HS022981.
Citation: Kansagara D, Chiovaro JC, Kagen D .
So many options, where do we start? An overview of the care transitions literature.
J Hosp Med 2016 Mar;11(3):221-30. doi: 10.1002/jhm.2502.
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Keywords: Caregiving, Hospital Discharge, Hospital Readmissions, Transitions of Care
Acher AW, LeCaire TJ, Hundt AS
Using human factors and systems engineering to evaluate readmission after complex surgery.
The study objective was to use a human factors and systems engineering approach to understand contributors to surgical readmissions from a patient and provider perspective. Patients and clinician providers identified a number of factors during the transition of care that may have contributed to readmission, including poor patient and caregiver understanding; inadequate discharge preparation for home care; insufficient educational process and materials.
AHRQ-funded; HS022446.
Citation: Acher AW, LeCaire TJ, Hundt AS .
Using human factors and systems engineering to evaluate readmission after complex surgery.
J Am Coll Surg 2015 Oct;221(4):810-20. doi: 10.1016/j.jamcollsurg.2015.06.014..
Keywords: Surgery, Hospital Readmissions, Hospital Discharge, Transitions of Care, Electronic Health Records (EHRs)
Black JT, Romano PS, Sadeghi B
A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better
The objective of this randomized controlled comparative effectiveness study was to evaluate the effectiveness of a care transition intervention that included pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight, blood pressure, heart rate, and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure.
AHRQ-funded; HS019311.
Citation: Black JT, Romano PS, Sadeghi B .
A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better
Trials 2014 Apr 13;15:124. doi: 10.1186/1745-6215-15-124..
Keywords: Cardiovascular Conditions, Comparative Effectiveness, Health Information Technology (HIT), Heart Disease and Health, Hospital Readmissions, Telehealth, Transitions of Care
Clancy CM
AHRQ Author: Clancy CM
New hospital readmission policy links financial and quality incentives.
This article describes AHRQ-related projects to reduce hospital readmissions, including Porject RED (Re-Engineered Discharge), Project BOOST (Better Outcomes for Older adults through Safe Transitions), and Patient Safety Organizations (PSOs).
AHRQ-authored.
Citation: Clancy CM .
New hospital readmission policy links financial and quality incentives.
J Nurs Care Qual 2013 Jan-Mar;28(1):1-4. doi: 10.1097/NCQ.0b013e3182725d82.
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Keywords: Elderly, Hospital Discharge, Patient Safety, Hospital Readmissions, Transitions of Care