Author Affiliation: Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, Texas.
My colleagues and I agree with Dr Ota that transitional care programs are needed and are intrigued by the idea of a dedicated physician transitionalist program. Better coordination at transitions of care, especially from discharge back to the outpatient setting, are required to improve care in chronic disease and will often necessitate in-person interventions. However, as our study showed, significant benefit can be achieved without a physician having to perform the actual visits.1 Advanced practice nurses (and maybe other health care providers) could work under the guidance of a physician transitionalist to improve outcomes and reduce readmissions.
Stauffer BD. The Transitionalist: Optimizing Inpatient-to-Outpatient Transitions of Care—Reply. Arch Intern Med. 2012;172(1):81-82. doi:10.1001/archinternmed.2011.612