Honora L. Englander

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CONTEXT Predicting hospital readmission risk is of great interest to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison. OBJECTIVE To summarize validated readmission risk prediction models, describe their performance, and assess suitability for(More)
Patients are vulnerable to poor quality, fragmented care as they transition from hospital to home. Few studies examine the discharge process from the perspectives of multiple healthcare professionals. To understand care transitions from the perspective of diverse healthcare professionals, and identify recommendations for process improvement. Cross sectional(More)
BACKGROUND The benefits of anemia treatment in patients with heart disease are uncertain. PURPOSE To evaluate the benefits and harms of treatments for anemia in adults with heart disease. DATA SOURCES MEDLINE, EMBASE, and Cochrane databases; clinical trial registries; reference lists; and technical advisors. STUDY SELECTION English-language trials of(More)
With its focus on holistic approaches to patient care, caregiver support, and delivery system redesign, geriatrics has advanced our understanding of optimal care during transitions. This article provides a framework for incorporating geriatrics principles into care transition activities by discussing the following elements: (1) identifying factors that make(More)
Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions. To evaluate the(More)
BACKGROUND Uninsured and Medicaid patients are particularly vulnerable as they transition from hospital to home. Transitional care improvement programs require time and capital, incentives for which may be unclear for those lacking a third-party payor. This article describes our experience developing a hospital-funded transitional care program for uninsured(More)
BACKGROUND Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply. PURPOSE 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(More)
BACKGROUND Residency training and evaluation are moving toward competency-based models. Managing transitions of care is 1 of 16 entrustable professional activities (EPAs) that signal readiness for independent internal medicine practice. Methods for developing EPAs are evolving within the medical education community. OBJECTIVE We describe a process for(More)