Six weeks. Forty-two days. 1,008 hours. No matter how you add it up, it's a long time to be stuck in a hospital bed. Unfortunately, that's how long my father-in-law was hospitalized — correction, rehospitalized — following surgery to remove a cancerous section of his esophagus. It felt like an eternity for him and the entire family — his six children, five in-laws and 13 grandchildren.

Regular readers of my blog in H&HN Daily are familiar with the story: Nearly a year after losing his wife to cancer, my father-in-law was diagnosed with esophageal cancer. Following an intense regimen of chemo and radiation, he had major surgery at a well-regarded academic medical center. The surgery went well, but my father-in-law developed pneumonia while in the ICU, complicating his recovery. He was discharged after 13 days, but the family was given little information about a care plan, medication reconciliation, necessary follow-up, etc. In fact, it wasn't until the day of discharge that we were told he'd need 24-hour care for a few weeks as he regained his strength and learned how to manage his feeding tube.

The next two weeks were rough. My wife, her sisters and brother took turns tending to their father. None of them are trained health care providers; all have jobs and families of their own that were put on hold. Several postsurgical complications ensued. Eventually, my father-in-law's primary care physician, who had been out of the loop since the surgery, got him admitted to a community hospital. He was there for six weeks before being discharged in mid-December. This time, the planning process worked. We knew what to expect. Follow-up appointments were set up, including one with his primary care doc. He hired a live-in nurse to help manage his recovery for a few weeks and to be there when the physical therapist visited. She drilled the former Marine endlessly on using the feeding tube and helped him understand how to introduce solid foods slowly back into his diet.

I saw my father-in-law just before the holidays and he looked great. He was sitting on the sofa watching football and writing out holiday cards. He and his nurse bickered like an old married couple, but he didn't skip a beat when she told him it was time to hook up to the feeding tube.

Our situation is not unique. Patients and families across the country confront the problems of poor care coordination and discharge planning every day. But there are glimmers of hope. Hospitals and others in the field are exploring ways to revamp the process and ensure that patients are getting the right care once they leave the hospital.

As we report this month in InBox [page 16], Rhode Island hospitals and the state's Blues plan are tying a significant portion of reimbursement dollars to well-executed discharge planning. In Illinois, the hospital association and Blue Cross Blue Shield have partnered to advance a program that seeks to improve transitions of care. And the New Jersey Hospital Association recently launched a tool aimed at helping hospitals improve care coordination.

With Medicare penalties for readmissions looming on the horizon, the pressure will only mount on providers to focus their energies on improving transitions of care.

Let me know what you think. You can reach me at