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Hospital discharge care transition represents a vulnerable period in the clinical care of patients. As many as 20% of patients experience adverse events within the first few weeks following hospital discharge, and, similarly, nearly 20% of hospitalized Medicare patients are readmitted to the hospital within 30 days of discharge (JW Hosp Med Apr 1 2009).
Investigators followed a prospective cohort of 65 patients who were admitted to internal medicine teams at a single tertiary care hospital to identify the percentage of patients who did not receive timely follow-up (defined as within 4 weeks) after hospital discharge and the effect of late follow-up on readmission rates. Patients were interviewed during initial hospitalizations and 4 weeks af…