Sometimes when I hear the phrase “care transitions,” I picture a patient stretched out on a conveyor belt, chugging down an assembly line. White-coated clinicians stationed at certain points along the way poke and prod and administer whatever they need to administer until he’s out of sight and out of mind, and then they turn all their attention to poking and prodding the next patient chugging down the line.

Yes, comparing health care to an assembly line is wrong on many levels. Good clinicians aren’t automatons performing the same task over and over. They tailor services to individual circumstances, and they’re concerned about their patients even after they’ve left their watch. But these days, we’re all paying more attention to the process of patient transitions. Hospitals are improving handoffs during shift changes and between units. Beefed-up discharge and post-discharge processes ensure that patients understand their instructions and follow through. Relationships between hospitals and post-acute providers have been strengthened so nothing gets lost in the shuffle. And big bucks are being spent on all manner of technologies.

One example: Our Most Wired cover story includes a case study on Lakeland Regional Medical Center, which employs what it calls a readmissions calculator. The tool helps to identify patients with congestive heart failure who are at risk of returning to the hospital within 30 days of discharge. Transition coaches then work with those patients to make sure they’ve filled their prescriptions, and that they take their meds and otherwise follow their treatment plans. 

Random Musings

The Not-So-Humble House Call

Most of us would prefer to be cared for at home no matter how dicey our medical issues may be. Making that happen could be good for the nation’s bottom line, too. Medicare in June announced that it had saved more than $25 million in the first year of a three-year study to determine the value of home-based primary care for frail seniors with multiple chronic illnesses. The AP’s Lauran Neergaard reports that the “humble house call” brings a doctor or nurse practitioner, sometimes accompanied by a social worker, to homebound patients whose needs are too complex for a 15-minute office visit and who might have a hard time getting to a physician’s office. “If we can keep people as healthy as possible and at home, so they only go to the hospital or emergency room when they really need to,” Neergard quotes Patrick Conway, Medicare’s chief medical officer, “that both improves quality and lowers cost.”

Protecting Teaching Hospitals

A June TrendWatch report from the American Hospital Association warns that changing how Medicare helps to finance graduate medical education “will undermine the overall financial support for teaching hospitals to continue training a talented and diverse pool of physicians.” It could also imperil the other services teaching hospitals provide, often in disadavantaged communities. For example, the TrendWatch notes, teaching hospitals house 82 percent of the nation’s Level I trauma centers, 78 percent of burn units, 74 percent of advanced certified stroke centers, 63 percent of pediatric intensive care units and 50 percent of surgical transplant services. For more, visit