Hospital readmissions remain a significant challenge in patient care, often leading to worse outcomes for patients who leave the facility prematurely. At SHM Converge 2026, Michael Schnaus, MD, Benji Mathews, MD, MBA, SFHM, and Paula Skarda, MD, presented data on a model transitions clinic designed to address this fragility. The group noted that studies suggest a substantial proportion of patients readmitted within 30 days face significantly raised mortality risk in the year that follows, highlighting the critical need for improved handoffs at discharge.
The program began in early 2024 as a response to a gap in post-discharge care for pulmonary patients. Hospitalists started seeing these patients after discharge through a virtual chronic obstructive pulmonary disease (COPD) pilot launched in March 2024. The initiative relied on automatic referrals for any patient with COPD on their problem list at discharge. 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 early data 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. These figures represent a significant improvement compared to a non-matched cohort of COPD patients.
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By May 2025, the program expanded as hospital medicine took full control and partnered with primary care for operational support. The model grew to include congestive heart failure (CHF) patients and those over 65 years of age. The current volume reflects 70 CHF visits for every 30 COPD visits. Today, a team of seven hospitalists staffs the clinic, which has supported more than 400 patients since the transition to hospital medicine leadership.
The staff includes an interdisciplinary team of physicians, social workers, pharmacists, and nurses who see patients within three to five days of discharge by telephone, video, or in person. The team identified a phenomenon they 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.
Hospitalists are uniquely positioned to lead in the post-discharge space. They 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.
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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.
As the program matures, the HealthPartners team is looking toward a future state that further integrates technology and streamlines professional communication. Future considerations 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.
