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Optimizing Transitions of Care: Lessons from a Hospital Medicine Transitions Clinic - On Demand 2026
Freshly discharged patients face their highest-risk window; a hospitalist-led transitions clinic, grown from a virtual COPD pilot into a multi-condition hybrid model, reveals how to reduce readmissions and improve key measures. You’ll analyze disease-specific pathways and medication workups, design collaborations across settings, explore data tactics, and apply lessons that advance value. Leave with a blueprint to create your own program.
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Availability
On-Demand
Expires on Apr 05, 2029
Credit Offered
0.75 CME Credit
0.75 ABIM-MOC Point
0.75 Participation Credit
  • Overview
  • Faculty
  • Accreditation
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Learning Objectives
After completing this activity, learners should be able to:
  1. Describe the structure and workflows of a hybrid Transitions Clinic model within hospital medicine, including integration of virtual and in-person care.
    Explain how disease-specific care pathways, such as those for COPD and CHF, can be embedded into post-discharge planning to reduce readmissions and improve care coordination.
  2. Identify the hospitalist’s critical role in supporting institutional performance on CMS Hospital Readmissions Reduction Program (HRRP) metrics through timely transitions of care.
  3. Demonstrate how hospitalist-led Transitions Clinics can improve value-based care (VBC) outcomes, including reductions in avoidable readmissions, improved medication optimization, and increased patient engagement.
  4. Evaluate common implementation barriers (e.g., staffing, EMR limitations, patient access, referral processes) and strategies to overcome them when developing scalable, system-level transitions programs.
Faculty
  • Michael Schnaus, MD
  • Benji Mathews, MD, MBA, SFHM
  • Paula Kay Skarda, MD, Professor, APD U of M

Faculty Disclosures
The individuals in control of content for this activity have no relevant relationships with ACCME-defined ineligible companies to disclose unless listed here. Any relevant relationships were mitigated prior to the start of this activity.

CME Credit Statement
The Society of Hospital Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

MOC Credit Statement
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75  MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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