SHM Converge Scientific Abstract ePoster Gallery-Heterogeneity and Misaligned Incentives in Discharge Transition Programs: Insights From a Multi-Site Rapid Qualitative Study

Pdf Summary

This multi-site rapid qualitative study examined why discharge transition of care (ToC) programs vary so widely across U.S. hospitals and why many fail to fully support patients with multimorbidity and health-related social needs (HRSNs). Researchers conducted virtual focus groups with 22 hospital medicine leaders from 19 organizations in the Hospital Medicine Reengineering Network (HOMERuN) and analyzed the discussions using a mixed inductive-deductive approach.<br /><br />A key finding was that none of the participating organizations offered a truly comprehensive ToC program. Instead, many relied on diagnosis-specific programs, which may help certain patients but also fragment care, especially for those with multiple chronic conditions who need coordinated support across diagnoses.<br /><br />Four major themes emerged:<br />1. Diagnosis-specific programs can be effective but often create fragmented care.<br />2. Post-discharge follow-up is difficult because of limited appointment availability, insurance obstacles, and geographic barriers.<br />3. Many programs do not adequately address patient preferences, HRSNs, or health literacy, and they often lack sufficient staffing, resources, and leadership backing.<br />4. Strong programs require institutional commitment, dedicated funding, teamwork across disciplines, and meaningful community partnerships.<br /><br />Participants emphasized that ToC programs are often shaped by financial incentives and short-term return on investment, rather than by patient-centered goals. The study concludes that current ToC efforts are fragmented and can undermine safe, equitable transitions from hospital to home. Improving outcomes will require more attention to social needs, better leadership support, and a shift away from narrow financial metrics toward patient-centered care.

Asset Subtitle

Molly Rosenthal

Meta Tag

Author List Aaron Fisher, Angela Keniston, Eva Angeli, Himali Weerahandi, Jeffrey L. Schnipper, Marisha Burden, Mark v. Williams, Molly Rosenthal, Safa Farag, Sara Westergaard, Sonia Dalal, Timothy Anderson

Category Research

Concept Transitional Care

Concept Patient Safety

Concept Discharge Transition Program

Concept Social Needs

Concept Incentive Misalignment

Distinguished Non-Finalist

Presenter Organization Harborview Medical Center, University of Washington Medicine

Presenting Author Molly Rosenthal

Track Transitions of Care

Keywords

transition of care

discharge planning

multimorbidity

health-related social needs

hospital medicine

post-discharge follow-up

care fragmentation

patient-centered care

leadership support

community partnerships

Transitional Care

Patient Safety

Discharge Transition Program

Social Needs

Incentive Misalignment