Nashville has always understood that the magic happens in the handoff, the moment one musician passes the melody to the next without missing a beat. In hospital medicine, that handoff is at discharge, and it is far more fragile than we like to admit. At SHM Converge 2026, Michael Schnaus, MD, Benji Mathews, MD, MBA, SFHM, and Paula Skarda, MD, opened with a sobering reality: studies suggest that a substantial proportion of patients readmitted within 30 days face significantly elevated mortality risk in the year that follows. Transitions of care, as Dr. Mathews put it, are where risk concentrates, and the presenters came with a model to address it.
From Pilot to Program
The story of the model transitions clinic began in early 2024, when a gap in post-discharge care for pulmonary patients prompted a question: What if hospitalists started seeing these patients after discharge? That idea became a virtual chronic obstructive pulmonary disease (COPD) pilot, launched in March 2024, built around automatic referrals for any patient with COPD on their problem list at the time of discharge. The visits were conducted by phone or video and focused on four core questions: Is the patient getting worse? Are medications reconciled and affordable? Is the follow-up plan appropriate? And does the patient have a clear action plan if symptoms worsen?
The data from those early years proved the model’s value; it achieved a 7.4% 30-day readmission rate for the pilot cohort, brought 84% of patients onto guideline-directed therapy, and ensured 89% of patients left with a COPD action plan, all significantly improved compared to a non-matched cohort of COPD patients.
Much like a band adding instruments to fill out its sound, the program expanded in May 2025 when hospital medicine took full control and partnered with primary care for operational support. By July 2025, the clinic had grown to include congestive heart failure (CHF) patients and those over 65 years of age, with the current volume reflecting 70 CHF visits for every 30 COPD visits. Today, the “bench” has deepened to seven hospitalists staffing the clinic, which has supported more than 400 patients since the transition to hospital medicine leadership.
Strategic Gap Closure
The clinic is staffed by an interdisciplinary team of physicians, social workers, pharmacists, and nurses, seeing patients within three to five days of discharge by telephone, video, or in person. What the team found, visit after visit, was a phenomenon they came to call the “cloud of hospitalization,” the predictable confusion that sets in once a patient leaves the hospital. Diagnoses are misunderstood, medications are duplicated or abandoned, and follow-up plans evaporate.
Design Principles
For hospitalists looking to replicate this model, the presenters emphasized four principles that guided the clinic’s development.
First, prioritize quality over volume with 30-minute visits, capped at 13 to 14 encounters per full day, with return on investment measured in readmissions prevented, not relative value units generated.
Second, target your gaps by identifying what your institution is missing and building your visit templates around closing those deficits.
Third, keep the interdisciplinary team connected through a shared real-time communication channel.
Fourth, establish clear guardrails around which patients qualify and what happens when they deteriorate.
Future Directions
As the program matures, the HealthPartners team is looking toward a future state that further integrates technology and streamlines professional communication. Future considerations for the model include the implementation of point-of-care ultrasound (POCUS) to assist with bedside assessments and prevent readmissions, as well as expansion to all highest-impact comorbidities. By adopting these principles and looking toward advanced diagnostic integration, institutions can move away from reactive care and toward a proactive, integrated approach that puts the patient’s recovery at center stage.
Key Takeaways
Hospitalists are uniquely positioned to lead in the post-discharge space. We understand acute illness, system risk, and care transitions in ways no other specialty does, and that knowledge should not stop at the hospital door.
The return on investment for a transitions clinic is not relative value unit generation; it is readmission prevention, quality metric improvement, and moving patient care forward. Build your business case around that.
Start with a focused patient population and specific, measurable gaps, demonstrate early results, and use that data to earn institutional buy-in before scaling. Quality over volume is the governing principle.
Dr.Oran
Dr. Choudry
Dr. Oran is a hospitalist and throughput director at MedStar Washington Hospital Center, and an assistant professor of medicine at Georgetown University School of Medicine, both in Washington, D.C. Dr. Choudry is associate division chief of hospital medicine and an academic hospitalist at MedStar Washington Hospital Center, and an assistant professor of medicine at Georgetown University School of Medicine, both in Washington, D.C.