{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T11:10:17Z","timestamp":1789038617882,"version":"build-2803163510"},"reference-count":41,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["shmpublications.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Hospital Medicine"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Older adults face a high risk of unplanned hospital readmissions during transitions from hospital to home. Despite system\u2010wide initiatives, substantial variation persists across Veterans Health Administration (VHA) facilities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To identify organizational factors and transitional care processes associated with high and low readmission rates.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a qualitatively driven explanatory sequential study of 10 VA medical centers selected based on 30\u2010day risk\u2010adjusted readmission rates. Ten facilities (five high\u2010performing, five low\u2010performing) were purposively sampled for qualitative investigation. Semi\u2010structured interviews with clinicians explored discharge planning, communication, and follow\u2010up care. Data were analyzed using rapid qualitative analysis and thematic matrices.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Based on interviews with 54 clinicians, we found that high\u2010performing facilities consistently implemented pharmacist\u2010led medication reconciliation, ensured patients received medications prior to discharge, scheduled follow\u2010up appointments before discharge, and engaged leadership in monitoring readmission metrics. These processes were enabled by organizational conditions such as clear role delineation, effective communication systems, and adequate staffing capacity. Low\u2010performing facilities faced compounding barriers, including unclear accountability, fragmented communication, and capacity constraints that undermined execution despite similar policies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Reducing readmissions needs more than clinical protocols; organizational readiness is critical. Investments in team structure, communication protocols, and capacity may yield greater and more sustainable improvements than adding new programs.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/jhm.70447","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T10:34:46Z","timestamp":1789036486000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Role clarity and organizational capacity as prerequisites for reducing readmissions: Comparing high\u2010 and low\u2010performing VA facilities"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9683-889X","authenticated-orcid":false,"given":"Nicholas A.","family":"Rattray","sequence":"first","affiliation":[{"name":"Department of Veterans Affairs (VA) Health Systems Research (HSR) Expanding Expertise Through E\u2010health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI) Indianapolis Indiana USA"},{"name":"VA HSR Center for Health Information and Communication (CHIC) Richard L. Roudebush VA Medical Center Indianapolis Indiana USA"},{"name":"Division of General Internal Medicine and Geriatrics, Department of Medicine Indiana University School of Medicine Indianapolis Indiana USA"},{"name":"Regenstrief Institute Indianapolis Indiana USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mindy E.","family":"Flanagan","sequence":"additional","affiliation":[{"name":"Department of Veterans Affairs (VA) Health Systems Research (HSR) Expanding Expertise Through E\u2010health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI) Indianapolis Indiana USA"},{"name":"VA HSR Center for Health Information and Communication (CHIC) Richard L. 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