A Reengineered Hospital Discharge Program to Decrease Rehospitalization
Annals of Internal MedicinePublished 3 February 2009
Brian Jack, V. K. Chetty, David Anthony, Jeffrey L. Greenwald, Gail M. Sanchez, Anna E. Johnson
Citations131
SJR quartileQ1
SJR score3.38
SNIP3.27
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Abstract
Emergency department visits and rehospitalization are common after hospital discharge. Jack and colleagues demonstrated that a nurse discharge advocate and clinical pharmacist working together to c...
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MedicineHealth Professions
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1,815 Citations1989L. J. Wei, D. Y. Lin +1 more
JAMAComprehensive Discharge Planning and Home Follow-up of Hospitalized Elders
1,766 Citations1999Mary D. Naylor, Dorothy Brooten +5 more
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PubMedRapid estimate of adult literacy in medicine: a shortened screening instrument.
1,614 Citations1993Terry C. Davis, Sandra W. Long +5 more
The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.
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New England Journal of MedicineDoes Increased Access to Primary Care Reduce Hospital Readmissions?
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Journal of General Internal MedicineMedical errors related to discontinuity of care from an inpatient to an outpatient setting
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PubMedAdverse events among medical patients after discharge from hospital.
749 Citations2004Alan J. Forster, Heather D. Clark +6 more
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Annals of Internal MedicineComprehensive Discharge Planning for the Hospitalized Elderly
731 Citations1994Mary D. Naylor, Dorothy Brooten +4 more
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Mayo Clinic ProceedingsPatients' Understanding of Their Treatment Plans and Diagnosis at Discharge
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Journal of Clinical EpidemiologySelf-reports of health care utilization compared to provider records
409 Citations2001Philip L. Ritter, Anita L. Stewart +4 more
There was no association between demographic or health variables and the tendency toward discrepancy between self-report and computerized utilization record reports, however, there was a tendency for the discrepancy to increase as the amount of record utilization increased.
Annals of Internal MedicinePatient Safety Concerns Arising from Test Results That Return after Hospital Discharge
396 Citations2005Christopher L. Roy, Eric G. Poon +5 more
It is hypothesized that test results pending at discharge are frequently overlooked in the handoff from the inpatient physician to the outpatient physician and that some of these results might have important clinical consequences for patients.
Journal of Clinical EpidemiologyComparison of self-reported and medical record health care utilization measures
363 Citations1996Rosebud O. Roberts, Erik J. Bergstralh +2 more
It is suggested that self- reported inpatient nights in the previous year and ambulatory physician visits in 2 weeks are reasonably accurate, but self-reported ambulatory doctor visits in thePrevious year may be less accurate and likely to be biased toward underreporting at higher numbers of visits.
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