Effectively transitioning patients from the hospital to home is an important priority for many hospitals and health care providers. Increasingly, reports have highlighted gaps in the quality of care that arise during and after hospital discharge. Also, external pressures to measure and report on the patients’ hospital care experience, and potential financial penalties for excessive readmission rates, have inspired health care organizations to focus on improving this process.


To improve the health of hospitalized patients statewide by developing a network of collaborative organizations focused on the problem of transitions of care. Hospitals partner with physician organizations (PO) to implement the Society of Hospital Medicine’s (SHM) BOOST program, and are supported financially and administratively by the state’s largest health plan.


We established a learning network composed of 24 POs partnered with 22 hospitals to implement best practices in care transitions. These organizations work together to improve transitions of care processes from the hospital to the ambulatory setting, share knowledge and experience with each other in regularly scheduled face to face quarterly meetings, and measure the impact of their efforts. A survey of POs and hospitals participating in the collaborative revealed that, among the 41 sites reporting, 80% agreed or strongly agreed that this program has helped the organization’s efforts to improve care transitions, while 8% disagreed. An additional 13% were not certain of the impact yet. One of the key lessons from our experience thus far has been to better understand the challenges associated with, and the opportunity to leverage the work on improving care transitions when POs and hospitals join together in this quality improvement initiative. While most sites feel that it is too early to determine whether participation in this program has had an impact on 30 day readmission rates, or 14 day ED return rates, many have commented that their organization has been able to work together on the specific components related to improving the transitions of care work that have previously been unaddressed. There have been, however, 2 POs and 2 hospitals that needed to drop out from this state–wide collaborative as they quickly realized the need to better align the PO and the hospital together in this work. They hope to rejoin this network in the future.


Improving transitions from the hospital to the ambulatory setting requires all stakeholders to come together and work to close the identified gaps in the process. Through the support of a major health plan, and utilizing SHM’s Project BOOST to analyze and redesign systems of care, a network of collaborative learning health care organizations have come together to share and inspire each other with an aligned goal to improve the overall health of all those we serve in our state in their transitions from the hospital.