As hospitals work to reduce avoidable hospital readmission rates, health care delivery systems more broadly have been working to develop efficient, effective health care delivery models under the rubric of accountable care organizations (ACOs). As the principal providers of inpatient‐based care, hospitalists can build on their quality improvement experience in transitions of care to play a key role in the development of local ACOs.


To leverage the previously established statewide multisite hospital–Physician Organization (PO) collaborative on Transitions of Care (ToCs) to align and integrate with existing and newly established efforts on ACO models of care.


We previously established a learning network comprising 25 POs working with 24 hospitals to implement best practices in care transitions. Each organization used SHM's BOOST tools, measured the impact of their efforts, and shared best practices at quarterly meetings. In addition, our collaborative utilized the SHM's mentored implementation model to assist participating sites in learning about how hospital‐based providers can play a key role in population health management approaches such as ACO's Primary Care Transformation initiatives (PCT), Organized Systems of Care (OSC), and the Community Based Care Transitions Program (CCTP). Areas of focus included communication between primary care physicians and hospitalists, reconnecting patients with PCP medical homes following discharge, monitoring how frequently patients are able to make their follow‐up appointments within 7 days, and facilitating dialogue between POs and hospitalists regarding the quality and timely transmission of information about the hospitalization. In addition to collecting readmission rates for the ToC units and the hospital, other measures aimed at assessing hospital–PO working relations in patient care coordination were also collected. Among a sample of 3158 discharged patients, 43% had a PCP follow‐up appointment scheduled, and 39% were seen within 7 days. A survey of PCPs' satisfaction with timely receipt of information from hospital providers revealed 56% were satisfied, but only 17% felt they received needed information from the hospital all the time. A qualitative survey of participating POs and hospitals revealed the most commonly cited area of progress has been obtaining the postdischarge appointment with a PCP within 7 days, and the most challenging area cited has been to facilitate communication between the PCP and the hospital. They also noted that they valued the quarterly meetings and time with their mentors to clarify and improve coherence of the multiple initiatives across the state on ToC and ACO/OSC development.


As the structure of health care delivery moves toward greater accountability for the patient across sites of care and providers, it is critical for hospitalists, hospitals, and ambulatory‐based primary care physicians to be knowledgeable about and integrated into these ACO/OSC development efforts.