***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To test the hypothesis that missing primary care follow-up plans in the discharge summary is associated with higher 30-day readmissions . STUDY DESIGN This retrospective cohort study included pediatric patients discharged from Mattel Children 's Hospital , University of California , Los Angeles between July 2008 and July 2010 . Exclusions included deaths , transfers , neonatal discharges , stays under 24 hours , and patients over 18 years of age . Bivariate and propensity weighted multivariate logistic regressions tested relationships between 30-day readmission and patient demographics , illness severity , and documentation of primary care provider ( PCP ) follow-up plans at discharge . RESULTS There were 7794 index discharges ( representing 5056 unique patients ) , with 1457 readmissions within 30 days ( 18.7 % ) . Average length of stay was 6.3 days . Being 15 - 18 years old , ( OR 1.42 [ 1.02 - 1.96 ] ) , having public insurance ( OR 1.48 [ 1.20 - 1.83 ] ) , or having higher All-Patient Refined Diagnosis-Related Group severity scores ( for severity = 4 vs 1 , OR 6.88 [ 4.99 - 9.49 ] ) was associated with increased odds of 30-day readmission . After adjusting for insurance status , Asian ( OR 1.46 [ 1.01 - 2.12 ] ) but not Black or Hispanic , race/ethnicity was associated with greater odds of readmission . Fifteen percent of 172 medical records from a r and omly selected month in 2010 documented PCP follow-up plans . After adjusting for demographics , length of stay and severity , documenting PCP follow-up plans was associated with significantly increased odds of 30-day readmission ( OR 4.52 [ 1.01 - 20.31 ] ) . CONCLUSION Readmission rates are complex quality measures , and documenting primary care follow-up may be associated with higher rather than lower 30-day readmissions . Additional studies are needed to underst and the inpatient-outpatient transition BACKGROUND Patients with complex care needs who require care across different health care setting s are vulnerable to experiencing serious quality problems . A care transitions intervention design ed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates . METHODS R and omized controlled trial . Between September 1 , 2002 , and August 31 , 2003 , patients were identified at the time of hospitalization and were r and omized to receive the intervention or usual care .  The setting was a large integrated delivery system located in Colorado . Subjects ( N = 750 ) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions . Intervention patients received ( 1 ) tools to promote cross-site communication , ( 2 ) encouragement to take a more active role in their care and to assert their preferences , and ( 3 ) continuity across setting s and guidance from a " transition coach . "  Rates of rehospitalization were measured at 30 , 90 , and 180 days . RESULTS Intervention patients had lower rehospitalization rates at 30 days ( 8.3 vs 11.9 , P = .048 ) and at 90 days ( 16.7 vs 22.5 , P = .04 ) than control subjects . Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days ( 5.3 vs 9.8 , P = .04 ) and at 180 days ( 8.6 vs 13.9 , P = .046 ) than controls . The mean hospital costs were lower for intervention patients ( $ 2058 ) vs controls ( $ 2546 ) at 180 days ( log-transformed P = .049 ) . CONCLUSION Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization OBJECTIVE To determine whether parent-reported quality of primary care was associated with subsequent health care use for children with special health care needs . DESIGN Secondary analysis of prospect ively collected data . SETTING The 2004 - 2005 and 2005 - 2006 Medical Expenditure Panel Survey panels . PARTICIPANTS A total of 1591 children with special health care needs . MAIN EXPOSURES Composite measures for family centeredness of care , timeliness of care , and realized access derived from the Consumer Assessment of Healthcare Providers and Systems survey . MAIN OUTCOME MEASURES Rates of parent-reported emergency department visits ( nonurgent and urgent ) and hospitalizations . Only encounters occurring after completion of the Consumer Assessment of Healthcare Providers and Systems survey were assessed . Weighted multivariate Poisson regression analyses , yielding incident rate ratios , were used for analysis . RESULTS Of the parents of the 1591 children included , 68.3 % rated family centeredness , 51.5 % rated timeliness , and 80.4 % rated realized access as high quality . Low- quality family centeredness was associated with higher rates ( incident rate ratio , 2.24 ; 95 % confidence interval , 1.32 - 3.80 ) of nonurgent emergency department visits compared with corresponding rates associated with high- quality family centeredness . There were no associations between quality -of-care domains and rates of urgent emergency department visits . For privately insured children , low- quality family centeredness was associated with higher rates ( incident rate ratio , 3.87 ; 95 % confidence interval , 1.23 - 12.13 ) of hospitalizations compared with corresponding rates associated with high- quality family-centered care . For publicly insured children , no significant associations were found . CONCLUSIONS Parent-reported , low- quality family centeredness was associated with higher rates of subsequent nonurgent emergency department visits and hospitalizations among children with special health care needs . These findings highlight family-centered care as a critical area for primary care intervention to reduce potentially preventable health care use IMPORTANCE Socioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status ( SES ) . Traditional hospital personnel often lack the time , skills , and community linkages required to address these factors . OBJECTIVE To determine whether a tailored community health worker ( CHW ) intervention would improve posthospital outcomes among low-SES patients . DESIGN , SETTING , AND PARTICIPANTS A 2-armed , single-blind , r and omized clinical trial was conducted between April 10 , 2011 , and October 30 , 2012 , at 2 urban , academically affiliated hospitals . Of 683 eligible general medical in patients ( ie , low-income , uninsured , or Medicaid ) that we screened , 237 individuals ( 34.7 % ) declined to participate . The remaining 446 patients ( 65.3 % ) were enrolled and r and omly assigned to study arms . Nearly equal percentages of control and intervention group patients completed the follow-up interview ( 86.6 % vs 86.9 % ) . INTERVENTIONS During hospital admission , CHWs worked with patients to create individualized action plans for achieving patients ' stated goals for recovery . The CHWs provided support tailored to patient goals for a minimum of 2 weeks . MAIN OUTCOMES AND MEASURES The prespecified primary outcome was completion of primary care follow-up within 14 days of discharge . Prespecified secondary outcomes were quality of discharge communication , self-rated health , satisfaction , patient activation , medication adherence , and 30-day readmission rates . RESULTS Using intention-to-treat analysis , we found that intervention patients were more likely to obtain timely posthospital primary care ( 60.0 % vs 47.9 % ; P = .02 ; adjusted odds ratio [ OR ] , 1.52 ; 95 % CI , 1.03 - 2.23 ) , to report high- quality discharge communication ( 91.3 % vs 78.7 % ; P = .002 ; adjusted OR , 2.94 ; 95 % CI , 1.5 - 5.8 ) , and to show greater improvements in mental health ( 6.7 vs 4.5 ; P = .02 ) and patient activation ( 3.4 vs 1.6 ; P = .05 ) . There were no significant differences between groups in physical health , satisfaction with medical care , or medication adherence . Similar proportions of patients in both arms experienced at least one 30-day readmission ; however , intervention patients were less likely to have multiple 30-day readmissions ( 2.3 % vs 5.5 % ; P = .08 ; adjusted OR , 0.40 ; 95 % CI , 0.14 - 1.06 ) . Among the subgroup of 63 readmitted patients , recurrent readmission was reduced from 40.0 % vs 15.2 % ( P = .03 ; adjusted OR , 0.27 ; 95 % CI , 0.08 - 0.89 ) . CONCLUSIONS AND RELEVANCE Patient-centered CHW intervention improves access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population . Health systems may leverage the CHW workforce to improve posthospital outcomes by addressing behavioral and socioeconomic drivers of disease . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01346462 ABSTRACT BACKGROUND  Patient activation  is linked to better health outcomes and lower rates of health service utilization . The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined . METHODS A secondary analysis using data from the Project RED-LIT r and omized controlled trial conducted at an urban safety net hospital . Data from 695 English-speaking general medical inpatient subjects were analyzed . We used an adapted , eight-item version of the vali date d Patient Activation Measure ( PAM )  . Total scores were categorized , according to st and ardized methods , as one of four PAM levels of activation : Level 1 ( lowest activation ) through Level 4 ( highest activation ) . The primary outcome measure was total 30-day post-discharge hospital utilization , defined as total emergency department ( ED ) visits plus hospital readmissions including observation stays . Poisson regression was used to control for confounding . RESULTS Of the 695 subjects , 67 ( 9.6 % ) were PAM Level 1 , 123 ( 17.7 % ) were Level 2 , 193 ( 27.8 % ) were Level 3 , and 312 ( 44.9 % ) were Level 4 . Compared with highly activated patients ( PAM Level 4 ) , a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation ( PAM Level 1 , incident rate ratio [ IRR ] 1.75 , 95 % CI,1.18 to 2.60 ) and ( PAM Level 2 , IRR 1.50 , 95 % CI 1.06 to 2.13 ) . The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 ( IRR 1.30 , 95 % CI , 0.94 to 1.80 ) . The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone ( 1.68(1.07 to 2.63 ) ) and for hospital readmissions alone ( 1.93 [ 1.22 to 3.06 ] ) . CONCLUSION Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization OBJECTIVES To evaluate an integrated telehealth intervention ( Integrated Telehealth Education and Activation of Mood ( I-TEAM ) ) to improve chronic illness ( congestive heart failure , chronic obstructive pulmonary disease ) and comorbid depression in the home healthcare setting . DESIGN R and omized controlled trial . SETTING Hospital-affiliated home healthcare setting . PARTICIPANTS Medically frail older homebound individuals ( N = 102 ) . INTERVENTION The 3-month intervention consisted of integrated telehealth chronic illness and depression care , with a telehealth nurse conducting daily telemonitoring of symptoms , body weight , and medication use ; providing eight weekly sessions of problem-solving treatment for depression ; and providing for communication with participants ' primary care physicians , who also prescribed antidepressants . Control participants were allocated to usual care with in-home nursing plus psychoeducation ( UC+P ) . MEASUREMENTS The two groups were compared at baseline and 3 and 6 months after baseline on clinical measures ( depression , health , problem-solving ) and 12 months after baseline on health utilization ( readmission , episodes of care , and emergency department ( ED ) visits ) . RESULTS Depression scores were 50 % lower in the I-TEAM group than in the UC+P group at 3 and 6 months . Those who received the I-TEAM intervention significantly improved their problem-solving skills and self-efficacy in managing their medical condition . The I-TEAM group had significantly fewer ED visits ( P = .01 ) but did not have significantly fewer days in the hospital at 12 months after baseline . CONCLUSION Integrated telehealth care for older adults with chronic illness and comorbid depression can reduce symptoms and postdischarge ED use in home health setting OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised 
    Output:
    
Postsurgical patients , those with neurologic disorders , and those with medical devices had higher preventable hospitalization rates , as did those with public insurance and nonwhite race/ethnicity .
Passive smoke exposure , nonadherence to medications , and lack of follow-up after discharge were additional risks .
Hospitalizations for ambulatory care sensitive conditions were less common in more complex patients .
Patients receiving home visits , care coordination , chronic care-management , and continuity across setting s had fewer preventable hospitalizations .
Risk of bias was moderate due primarily to limited controlled experimental design s. Reductions in hospital use among CMC might be possible .