Care Transition Models

One of the most meaningful parts of practicing neonatal medicine isn’t just stabilizing babies. It’s stabilizing confidence. In the NICU, we build systems around survival. But after discharge, families are often left to build systems around uncertainty. The monitors come off. The team steps back. And suddenly, parents are responsible for everything. Discharge is not the end of the journey. It’s the beginning of a new kind of vulnerability. And yet, our current care models often treat it like a handoff instead of a high-risk transition. What families need in that moment isn’t just a summary note. They need continuity. They need proactive guidance. They need a clinician who understands not only what is concerning today — but what could become concerning tomorrow. Over time, I’ve realized this isn’t just a clinical gap. It’s a design gap. We have built excellent systems for acute stabilization. We have not built equally strong systems for sustained confidence. That realization is what led me to launch a specialized continuity clinic for NICU graduates — a wraparound model designed to extend support beyond discharge and bridge the space between hospital care and long-term thriving. Because NICU graduates are more than their fragile beginnings. And their families deserve care models that evolve with them. Where do you see transition points in healthcare that are under-designed? *Posted with family permission.* #Neonatology #NICU #HealthcareInnovation #CareModelDesign #ContinuityOfCare #PhysicianEntrepreneur #WomenInMedicine #FamilyCenteredCare

One of the biggest challenges in healthcare today is knowing what happens between care settings. When a client leaves the hospital, their recovery journey doesn’t end, it often continues at home. Yet, too often, hospital systems and home care services operate in silos. Information doesn’t flow, data gets duplicated, and frontline staff are left to fill in the gaps. Picture this: nurses making visits to empty homes while patients receive duplicate services in hospital or respite centre. At discharge, the cycle repeats, patients return home without care teams being notified, creating dangerous gaps. The result? Clients fall through the cracks, care teams spend more time on travel and paperwork than care, and providers lack the data needed to for the future. System transformations with real impact happen when hospitals and home and community care can work together. Health PEI, the single health authority responsible for the entire continuum of care in Prince Edward Island, recognized this need and set out to modernize its home care system with AlayaCare. Their vision was clear: - Standardize assessments with evidence-based tools - Integrate home care directly with hospital and provincial systems - Empower staff with mobile access and real-time data - Reduce administrative burden and automate scheduling processes - Unlock insights for long-term planning and decision-making The results speak for themselves: - 100% of eligible clients now have multidisciplinary care plans - 216% increase in standardized assessments after replacing SAST with interRAI HC - 18% boost in scheduling productivity, enabling more care with the same resources - 50% reduction in clinical paperwork, giving staff more time to focus on care - Province-wide hospital integration strengthening care coordination across PEI Beyond the numbers, the transformation has had a profound human impact. Staff spend less time chasing paperwork, they can see in real time when a client has been admitted, discharged, or transferred. They document on the go, and most importantly, Clients receive care that is connected, consistent, and aligned with their needs. Health PEI’s story offers a blueprint for what home care transformation can look like at the provincial level: a shared vision, an integrated model of care, and measurable outcomes across the continuum. We’re proud of the work we’ve done together and look forward to continuing our partnership to support better outcomes across the province.

Looking to reduce 30-day readmission rates? A virtual transition of care clinic for high-risk patients immediately after discharge can help you get there. Recently, I had the pleasure of working with a group of researchers from UC San Diego School of Medicine and UC San Diego Health on a new study, published in JMIR Publications Informatics, that found patients seen virtually within a week of discharge had a 14.9% 30-day readmission rate, compared to 20.1% for the benchmark group. TOPLINE: ➡️ One-time virtual visits translate to better recovery at home, lower costs, and improved access for high-risk patients. UC San Diego Health launched our virtual transition of care clinic (VToC) in 2021. Supported by 12 hospitalists, two medical assistants, one pharmacist and an on-demand interpreter service, VToC has been instrumental in helping to reduce readmissions. "Our clinic is a one-time, virtual visit with a patient immediately after their hospital stay to ensure we’re doing all we can to mitigate risk," said lead author Sarah Horman, professor of medicine at UC San Diego School of Medicine and a Joan & Irwin Jacobs Center for Health Innovation @ UC San Diego Health  faculty affiliate. The study involved more than 25,000 participants cared for at UC San Diego Health from Sept. 1, 2021 to Sept. 17, 2024. Of the participants, 2,314 were seen in the virtual clinic and 23,129 had standard follow-up care as the study’s benchmark group. Co-authors ➡️ Milla Kviatkovsky, DO, MPH, Chad VanDenBerg, FACHE, John Bell, Christopher Longhurst & Edward Castillo, all with UC San Diego Health. Learn more about VToC and this important study ⤵️ https://lnkd.in/eYyy9HZd #telemedicine #telehealth #virtualcare #virtualhealthcare #UCSDHealth #QualityInCare #LeadershipInHealthcare #ContinuousImprovement #HealthCareExcellence

📣🏥👨👩👧👦 Moving Beyond Informal Support: Designing System-Ready Models of Family Engagement in Diabetes Care Across South Asia In our new article published in The Lancet Regional Health – Southeast Asia, we call for a fundamental shift in how health systems engage families in managing type 2 diabetes. Across South Asia, families are already at the center of daily care (preparing meals 🍛, managing medications 💊, providing emotional support 💬), yet their role remains informal and largely unsupported by healthcare systems. We argue that it is time to move toward intentional, equitable, and system-integrated models of family engagement. These approaches must reflect the realities of multigenerational households 🏠, gendered caregiving norms, and increasingly digital family interactions 📱. This means equipping family members with the tools, training, and support they need to contribute meaningfully, while ensuring they are not overburdened. These ideas build on reflections I shared recently in Nature Portfolio (https://lnkd.in/gpfFggsS), where I explored the promise of different models of family empowerment in supporting older adult care, especially in lower-resource settings. To help guide this transition, we outline three models of family involvement in diabetes care: 1) a family-supported model 🤝, where the individual with diabetes is the primary intervention recipient but receives encouragement and support from relatives; 2) a family-wide model 🏡, where both the patient and close family members are active participants, sharing intervention goals and responsibilities; and 3) a family-led model 🗣️, where a trusted family member is the main recipient of the intervention and takes the lead in managing and coordinating care. These frameworks are intended to spark fresh thinking around how we design, implement, and scale chronic disease interventions that meaningfully position families as part of the solution. While rooted in diabetes care, the models we propose have broad relevance across many areas of health, offering a foundation for more inclusive, sustainable, and community-informed approaches. Grateful to my fantastic co-authors Drs Sudip, Abhijit Chanda, and Biswadeep Dhar, for their insight and collaboration throughout this work 🙏 Read the article here: https://lnkd.in/geCHQ-5A #diabetes #publichealth #southasia #familyhealth #digitalhealth #healthsystems #chronicdisease

“Patients, primary care physicians, and oncologists face challenges transitioning from active treatment to ongoing survivorship care.” 👩⚕️👨⚕️ Healthcare professionals, it’s time we acknowledge a hard truth: our current, fragmented model underserves cancer survivors. A new review article makes a compelling case for embedding Lifestyle Medicine (LM)—nutrition, physical activity, restorative sleep, stress management, social connection, and risk reduction—as standard survivorship care from diagnosis onward. ⚠️ Why this matters? -Survivors carry high cardiometabolic risk (obesity, hypertension, diabetes, dyslipidaemia) that worsens fatigue, quality of life, treatment tolerance, and long-term outcomes. -Despite clear guidance (ACS/ASCO/WHO), very few survivors meet all lifestyle recommendations—a gap driven by training, workflow, access, and rampant online misinformation. 📊 What the evidence shows? -Exercise during/after treatment improves fatigue, fitness, function, and QoL with rare adverse events. -Diet quality (plant-predominant, minimally processed) is linked to lower mortality and better overall health. -Stress, sleep, and social health interventions reduce anxiety, improve sleep, and are associated with better survival. Programme examples: RENEW: ↑ physical activity by ~36 min/week, ↑ fruits & veg by ~1.2 servings/day, ↓ saturated fat, and ~2 kg weight loss at 12 months. SurvivorSHINE: ↑ lifestyle knowledge, modest ↑ activity, ↓ red meat/alcohol. Cleveland Clinic Abu Dhabi: ~35% improved glycaemic control after LM care 🧩 What successful models look like -EMR-integrated referral pathways with oncology-LM consults -Multidisciplinary teams (LM-trained clinicians, RDs, physio/exercise physiology, psychology, sleep, social work). -Group visits & virtual delivery (e.g. curricula PAVING the Path) -Community + hospital partnerships (Australia’s exercise-oncology scale-up) -Routine outcomes tracking (fatigue, function, PROs, metabolic markers) ✅ What you can do tomorrow? -Ask every survivor about movement, diet quality, sleep, stress, social support, tobacco/alcohol -Prescribe exercise; refer to qualified EP/physio. 🏃♀️ -Co-manage with an RD; shift toward plant-predominant, minimally processed foods 🥗 -Start a group programme (virtual works); lean on shared medical appointments 💬 -Build the pathway: EMR order sets, referrals, brief scripts, and patient education that counters misinformation -Measure what matters: fatigue scales, grip strength, HbA1c/lipids/BP, and PROMs. 📈 If we’re serious about value-based, person-centred oncology, LM can’t be “nice to have.” It’s the missing survivorship pathway—actionable, scalable, and equity-enabling through telehealth and group care. ❤️ https://lnkd.in/dYtBnSGg Beth Frates, MD Amy Comander, MD, DipABLM Nicole Sirotin, MD DipABLM FACP Sami (Papacek) Mansfield #CancerSurvivorship #LifestyleMedicine #Oncology #Exercise #PrimaryCare #Health #GroupVisits #Cancer

A night at Dodger Stadium and Angel Stadium taught me something about healthcare. As someone who helps healthcare organizations engage patients, visiting both ballparks recently made the contrast impossible to ignore. These two franchises share the same market and league, yet operate on fundamentally different philosophies that map onto decisions facing healthcare systems today. The Los Angeles Dodgers operate like a SaaS platform with a baseball team attached. Before you arrive, they are already reaching you. At the game, the MLB Ballpark app runs promotions and check-ins in real time. After the final out, feedback loops and retention campaigns begin. The Dodgers have invested heavily in AI-driven fan engagement, personalizing experiences, optimizing pricing, and tracking behavior across the full lifecycle. They treat every fan as a lifetime subscriber. The Los Angeles Angels operate on a different calculus. Owner Arte Moreno stated in February 2026 that, per the organization's own survey, winning does not rank in fans' top five priorities, with affordability, safety, and experience leading the list. The operational reality at Angel Stadium reflects that exactly: show up, enjoy the game, go home. The Angels treat every fan as a transactional guest. So what does this have to do with healthcare? Everything. Healthcare is caught between these two models, and both carry real merit and real blind spots. The Dodger Model is where chronic disease management, digital health, and value-based care are heading. The patient is not just a 15-minute visit. Care extends through a data-driven lifecycle: pre-visit outreach, in-facility navigation, and post-discharge monitoring that does not stop at the door. The upside: Proactive intervention, higher retention, and stronger patient relationships. The risk: Engagement fatigue. When digital touchpoints feel automated or impersonal, patients tune out and distrust follows. The Angel Model reflects what matters most to millions of patients in acute, episodic, and community care settings. For a first-generation patient navigating a complex system, or a family balancing cost and logistics, digital engagement becomes irrelevant when fundamentals are absent. Is the care affordable? Is it safe? Is the experience uncomplicated? These are the foundation. The risk: Passivity. Organizations that optimize only for the in-person moment lose the patient the second they walk out the door. The organizations I watch most closely are not choosing between these two models. They are sequencing. They earn the right to the digital relationship by getting the baseline right first, then layer the data infrastructure on top of a relationship the patient already trusts. Fix the turnstile. Then build the ecosystem. Which model is your organization closest to right now, and is that by design or by default? #HealthcareTechnology #DigitalHealth #PatientEngagement #PersistentSystems

We send new moms home with a new human and a 6-week wait. A study published this month in Health Affairs Scholar puts a fine point on something that should make everyone in maternal health uncomfortable even though we hear about it regularly: over half of maternal deaths in the US happen after hospital discharge, and most are preventable. The culprit isn't a lack of good intentions. It's a care model that treats birth as the finish line. The researchers offer a striking comparison: a hip replacement patient leaves the hospital with a care plan, follow-up appointments, and coordinated communication across providers. A postpartum mother leaves with a new human, limited guidance, and a single visit scheduled six weeks out by which time postpartum hypertension has already peaked, depression has gone unscreened, and no one has clearly established who's accountable for her care. The good news: the paper identifies three models that actually work. 1. Dyadic care: treating mom and baby together, not in siloed parallel systems 2. Home visiting: meeting families where they are, as most of the developed world already does with virtual care (closing the dangerous gap between discharge and that distant 6-week visit) 3. That third one is where the opportunity is sharpest, and where the US is most behind. The authors note that virtual modalities can address maternity care deserts (where 61% of cases are in rural areas), reduce logistical barriers like transportation and childcare, and enable earlier screening for the conditions that kill postpartum mothers: hypertension, depression, substance use. This is precisely what Ouma Health is built for. Ouma extends specialty-level postpartum support, mental health, high-risk follow-up, lactation, nurse navigation to patients across the nation, including the communities that need it most. No 6-week wait. No maternity care desert. No falling through the cracks between OB and primary care. The policy infrastructure is finally catching up too. Nearly every state has extended postpartum Medicaid coverage to 12 months. The AMA released new obstetric billing codes this April that for the first time separate and incentivize postpartum care. The window is open. The question is whether health plans, systems, and policymakers will move fast enough to walk through it. https://lnkd.in/g2VUQCRC #MaternalHealth #PostpartumCare #MaternalMortality #HealthPolicy #ValueBasedCare #Telehealth #HealthEquity #PerinatalHealth #HealthcareInnovation #Medicaid #WomensHealth #DigitalHealth

We Don’t Have a Long‑Term Care Spending Problem. We Have a Care Model Problem—and a Proven Solution. Long‑term services and supports (LTSS) are among the largest and fastest‑growing components of U.S. healthcare spending, particularly for older adults with complex needs. While individuals who are Medicare–Medicaid eligible make up a relatively small portion of beneficiaries, they account for a disproportionate share of total healthcare spend, driven largely by institutional care, avoidable hospitalizations, and fragmented delivery models. Nationally, long‑term care spending exceeds $450B annually, with nursing facility care alone often costing $100,000 or more per person per year. Yet despite this level of investment, outcomes too often fall short—clinically, financially, and humanely. This is not a failure of aging. It’s a failure of design. For decades, we have organized care around siloed systems—medical, behavioral health, pharmacy, and LTSS—each optimized independently, none accountable for the whole person. The result is predictable: high utilization, escalating costs, and diminished quality of life. PACE offers a fundamentally different care model. Programs of All‑Inclusive Care for the Elderly (PACE) realign incentives around what actually works: * Fully integrated, interdisciplinary care * Capitated, value‑based financing that rewards prevention * Community‑based delivery that prioritizes function, independence, and connection The evidence is consistent. PACE participants experience: * Lower emergency department use and hospitalizations * Reduced nursing home utilization * Lower total cost of care over time * High participant and caregiver satisfaction But the most important outcomes can’t be reduced to a dashboard. PACE enables older adults to remain at home, engaged in their communities, and supported as whole people—not a collection of diagnoses. It preserves dignity, autonomy, and social connection while delivering measurable value to Medicare and Medicaid. As policymakers, health plans, and providers confront the unsustainability of long‑term care spending, the question isn’t whether models like PACE work. The question is whether we are willing to scale what we already know delivers better outcomes at a lower cost. PACE is not a pilot. It’s a blueprint. #PACE #LongTermCare #LTSS #ValueBasedCare #PopulationHealth #TotalCostofCare #HeatlhcareTransformation #WholePersonCare #AgingWithDignity #CPHQ #CPPS #CPAFH #Medicare #Medicaid

CONTINUITY ARCHITECTURE Every health system has a care coordination program. Almost none have continuity architecture. That distinction explains why coordination investments plateau, AI pilots stall, and value based contracts underperform. Care coordination is a program layered on top of fragmentation. Continuity architecture is system design that prevents fragmentation by default. Programs depend on staffing levels, funding cycles, and heroics. Architecture survives leadership transitions, margin pressure, and strategic pivots. If your transitions fail, it is not a staffing problem. It is a design problem. Continuity Architecture is the structural framework that makes seamless patient transitions the default operating state not the exception that depends on who’s working that day. It operates across five domains: 1. Clinical Continuity One longitudinal plan of care that survives setting changes. Not discharge based thinking. Not episodic ownership. 2. Informational Continuity Context rich clinical intelligence delivered at the moment of handoff. Not document exchange. Not delayed summaries. 3. Accountability Continuity Named ownership at every transition node. No assumed responsibility. Measured handoffs. 4. Operational Continuity Transition reliability engineered into workflows, staffing models, and escalation pathways. Stability by design. 5. Financial Continuity Incentives aligned across the full care arc so outcomes not isolated episodes drive economics. Most systems have pieces of these. Almost none have intentionally engineered them to function together. That is the architecture gap. It is why readmissions persist despite coordination investment. Why post-acute leakage continues despite network expansion. Why digital transformation fails to produce durable ROI. Execution is not the primary failure point. Design is. I have spent two decades building this framework inside actual health systems. It finally has a name. Continuity Architecture. This is Post 1 in a six-part series on how to diagnose it, build it, and deploy it as a competitive operating advantage.

Most community health programs don’t fail from lack of funding. They fail because there’s no model for scale. Here are 3 frameworks that actually work, and when to use each one: Community-based care means solving health problems before they become hospital emergencies. But it’s not just “neighbours helping neighbours.” It’s a system of shared responsibility, with the right infrastructure behind it. That’s where co-care models come in: These are frameworks that blend clinical leadership with local ownership. They help turn one-off pilots into scalable systems that improve outcomes across entire populations. Here are 3 proven models: 1. Communities of Practice (CoP) CoPs bring together peers: CHWs, nurses, social workers, to solve shared challenges. No one is forced to join. People show up because the learning is real and the trust runs deep. CoPs work best when: • You need culture change • Teams are siloed • You want innovation from the ground up They’re ideal in early-stage or low-resource settings. Example: WHO’s CoPs in India improved rural TB treatment through peer-driven learning. 2. Quality Improvement Collaboratives (QIC) QICs unite multiple teams around a shared goal, like reducing ER visits or improving A1C. They use cycles: test a change, collect data, share results, repeat. Pioneered by the Institute for Healthcare Improvement. QICs are ideal when: • You need measurable outcomes • There's already strong clinical evidence • Accountability is essential They're widely used in hospitals, but gains can fade without sustained structure. 3. Clinical Community Model This model blends top-down strategy with bottom-up adaptation. A core team sets the goal. Frontline teams test solutions, share results, and shape how change spreads across the network. It’s ideal when: • You’re scaling across large systems • You need consistency + flexibility • Local adaptation is essential Example: NHS England used this model to reduce surgical site infections across 250+ hospitals. How do you choose the right model? Ask: • Do you need peer-led trust or fast metrics? • Is your goal culture shift—or compliance? • Are you scaling inside one org—or across many? Your model should match your mission. No framework is perfect. But every community program that lasts relies on some version of these models. Because structure isn’t bureaucracy. It’s what makes change stick. There are other models too: • Learning health systems • Social prescribing networks • Collective impact coalitions No matter which model you choose: Make sure it has clear roles, repeatable practices, and a way to scale beyond year one. That’s what turns a pilot into a system, and a good idea into real health outcomes. ↓ Thanks for reading! I'm Sam Armstrong, Founder of Kismet Healthcare. If you found this useful, follow me for insights on building community-driven businesses Repost for your network:🔄