Optimization of Patient Progression in a New Era: A Comprehensive Framework.

Autor:	Smith LE; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Escobar T; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., McCabe A; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Grafton J; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Higgins M; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Littlefield M; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Ray S; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Leung P; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Fiksdal A; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Khinkar RM; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Wilcox RB 3rd; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Yuse C; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Fillipon K; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Walsh T; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Morris CA; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Anderson S; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Pearson M; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA., Mendu ML; Laura E. Smith, MD, is Senior Medical Director of Clinical Operations, Department of Care Continuum Management, Office of the Chief Operating Officer, Brigham and Women's Hospital (BWH), Boston, MA.; Trancy Escobar, CMAC, MBA, is Executive Director, Complex Care and Post Acute Strategy, Department of Care Continuum Management, BWH, Boston, MA.; Andrea McCabe, MHA, BSN, RN, is Nurse Director, Department of Care Continuum Management, BWH, Boston, MA.; James Grafton, MSN, MHA, RN, CCM, is Director of Care Continuum Management, Department of Care Continuum Management, Brigham and Women's Faulkner Hospital, Boston, MA.; Margaret Higgins, MSN, RN, is Associate Chief Nursing Officer, Department of Care Continuum Management, BWH, Boston, MA.; Melissa Littlefield, MBA, is Senior Administrative Director of Care Continuum Management, Department of Care Continuum Management, BWH, Boston, MA.; Soumi Ray, PhD, MS, is Senior Data Analyst, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Peggy Leung, MS, is Director, Analytics and Reporting, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Alexander Fiksdal, PhD, MA, is Lead Clinical Data Scientist, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Roaa M. Khinkar, PharmD, CPPS, CPHQ, is Assistant Professor, Department of Pharmacy Practice, Quality Improvement and Patient Safety Specialist, King Abdulaziz University, Jeddah, Saudi Arabia.; Reg B. Wilcox III, DPT, MS, PT, is Executive Director of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Carolyn Yuse, DPT, is Clinical Supervisor of Rehabilitation Services, Department of Rehabilitation Services, BWH, MA.; Katie Fillipon, DNP, RN, NEA-BC, is Deputy Chief Nursing Officer; Associate Chief Nursing Officer for Oncology and Medicine, Office of the Chief Nursing Officer, BWH, Boston, MA.; Thomas Walsh, MBA, is Vice President, Inpatient Operations and Analytics, Planning, Strategy and Improvement, Department of Analytics, Planning, Strategy and Improvement, BWH, Boston, MA.; Charles A. Morris, MD, MPH, is Chief Medical Officer and Vice President of Medical Affairs, Office of the Chief Medical Officer, BWH, Boston, MA.; Shelly Anderson, MPM, is Executive Vice President and Chief Operating Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Madelyn Pearson, DNP, RN, NEA-BC, is Senior Vice President of Patient Care Services and Chief Nursing Officer, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.; Mallika L. Mendu, MD, MBA, is Vice President of Clinical Operations and Care Continuum Management, Department of Care Continuum Management, Office of the Chief Operating Officer, BWH, Boston, MA.
Jazyk:	angličtina
Zdroj:	Professional case management [Prof Case Manag] 2024 May-Jun 01; Vol. 29 (3), pp. 91-101.
DOI:	10.1097/NCM.0000000000000700
Abstrakt:	Purpose/objectives: The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments. Primary Practice Settings: Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign. Findings: Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days). Conclusions: Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings. Implications for Case Management Practice: The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration. Competing Interests: Conflicts of Interest: Dr. Laura Smith serves on the advisory board for New England Life Care, not relevant to the contents of this article. For the remaining authors none are declared. The authors report no conflicts of interest. (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)
Databáze:	MEDLINE
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