Transitions of Care and Preventable Readmissions

The Transitions of Care Project is a prospective observational study to help understand how hospital discharge coordination affects readmission, and to describe both patient and physician perceptions of readmission causality.

Principal Investigators
Andrew Auerbach, MD, MPH
S. Ryan Greysen, MD, MHS, MA, FHM
Michelle Mourad, MD
Urmimala Sarkar, MD, MPH


Despite intense scrutiny on the need to reduce readmissions, and a proliferation of models intended to improve care transitions, surprisingly little is known about the factors that affect readmissions, how to target interventions appropriately, or the degree to which variations in care practices (within or across sites) contribute to the likelihood of readmission. At the conclusion of our research study, we hope to have identified factors that are helpful in predicting how patients can safely and comfortably transition to home following an inpatient medical admission.