Implementation Science Workshop: Primary Care-Based Multidisciplinary Readmission Prevention Program

To define comorbidities including chronic obstructive pulmonary disease or asthma, heart failure, diabetes, hypertension, coronary artery disease, and depression, we required the condition to be listed either on the index hospitalization discharge summary or on the general problem list of the EHR; in addition, an appropriate medication to treat this condition had to be listed in the index hospitalization discharge summary. Cirrhosis and chronic kidney disease required only a mention of this condition in the discharge summary or problem list, and alcoholism was defined to include active problem drinking in the prior 6 months, as noted in the hospital discharge summary or clinic notes.