Bridging the Gap Between Inpatient and Outpatient Care.

Background: The Olin E. Teague Veterans' Center (OETVC) is a teaching hospital with a medical ward consisting of 189 beds, 3 teaching teams with 1 resident and 2 to 3 interns, and 3 nonteaching teams. Due to the complexity of hospitalization, there are concerns that patients may not follow up with primary care or fill their prescribed medication and may have postdischarge questions.