Discharge & Transitions Committee

Focus areas

Vision: Transform systems so that each hospital transition and discharge is safe for all patients.

Mission: Our mission is to improve transitions in care by identifying gaps in care, supporting innovations, evaluating their efficacy, and elevating, disseminating, and implementing effective interventions. We aim to do this by creating an environment where we can collaborate and improve on our current practices to improve the patient and clinician experience.

Values: Patient-centered; evidence-based; collaborative; diverse; innovative; clinician optimized

Strategic Goals

1. Understand variation in hospital transition & discharge practices across different settings

Broad topic


Project Ideas


Evaluation of current practices at HOMERuN sites compared with known best practices (Transitional Care Model, Care Transitions Program, Project RED, Project BOOST, GRACE)

Do we already know what works, or do we need innovation?

What best practices receded during the height of the COVID-19 pandemic? What needs to come back? What new practices emerged?

Discharge practices for patients with complex transition needs

  • Challenges of discharging patients with complex transition needs (lack of accepting SNFs, etc.)

What is the variation in discharge practices across different hospitals/ implementation of best practices

  • Who is involved, tech used

What is the variation within hospitals/across services with discharge practices

What do different stakeholders think is important in discharging a patient

Dr Mara Bann had a “what is a safe discharge” project representing patient opinion – could be multisite?

Rapid qualitative study and/or survey different hospitals through HOMERuN

  • Include data on vertically integrated SNFs

Update from Mara Bann regarding ‘what is a safe discharge’ work ongoing

What are factors largely outside the hospital’s control that impact discharge safety, and how do they impact discharge safety?

How social drivers of health vary by hospital catchment area

Variation based on hospital patient population

How current payment systems influence practice and ability to improve

Comparison of fee-for-service systems with self-ensured or capitated systems

Retrospective cohort study

Subgroup analysis of PLACER study (below)

Titrating discharge practices based on individual patient needs

How function and frailty impact discharge safety

Study evaluating accuracy of prediction tools for tiered system of outpatient follow-up

Systematic review or retrospective study

2. Advance the science of hospital transitions

Broad topic


Project Ideas


Comparative effectiveness research comparing different approaches to discharge from hospital

Examine variation of discharge practices among HOMERuN hospitals

Use rapid qual work demonstrating variation as preliminary data for PCORI PLACER grant

Matched cohort study from BWH quantifying readmission rates in home hospital c/w conventional hospitalization

PLACER grant to compare two interventions: might be Project RED or BOOST compared with home hospital

Avoid admission (and discharge)

Hospital at Home

Evaluation of VUMC Hospital at Home program? (Deonni Stolldorf)

What partnerships should hospitals make to improve discharge safety 


Vertically integrated SNFs

Identify new metrics to evaluate success of transitions/discharges

Move beyond 30-day readmission metric

Post-discharge adverse events

Patient experience after discharge, including activation, satisfaction, caregiver burden

Improve patient experience

Improve clinician experience

Not adding more to clinician workload with implementing new practices

Collaborative Team Lead Names

Molly Rosenthal, MD, Assistant Professor, University of Washington Medical Center

Himali Weerahandi, MD, MPH, Assistant Professor, UCSF (University of California, San Francisco)

Member names and institutions:

  • Maralyssa Bann, MD, University of Washington
  • Rachel Weiss, MD, University of Virginia School of Medicine
  • Matthew Mitchell, PhD, University of Pennsylvania Health System
  • Ryan Greysen, MD, MHS, University of Pennsylvania
  • Eva Angeli, MD, University of New Mexico
  • Efren Manjarrez, MD, University of Miami
  • Armond Esmaili, MD, University of California, San Francisco School of Medicine
  • Ifedayo Kuye, MD, MBA, University of California, San Francisco School of Medicine
  • Lekshmi Santhosh, MD, MAEd, University of California, San Francisco School of Medicine
  • Neal Tambe, MD, PhD, University of California, San Francisco School of Medicine
  • Esther Hsiang, MD, MBA, University of California, San Francisco School of Medicine
  • Jeffrey Schnipper, MD, MPH, Brigham and Women’s Hospital; Harvard Medical School
  • Himali Weerahandi, MD, MPH, University of California, San Francisco School of Medicine
  • Molly Rosenthal, MD, University of Washington
  • Tim Anderson, MD, MAS, University of Pittsburgh
  • Ting-Jia Lorigiano, MD, MBA, Johns Hopkins University
  • Mark Williams, MD, Washington University St. Louis
  • Allison Heacock, MD, The Ohio State University, Wexner Medical Center
  • Sunil Sahai, MD, University of Texas Medical Branch at Galveston
  • Gregory Leslie, MD, University of Massachusetts
  • Hernán Carrillo Bestagno, Las Higueras Hospital
  • Consuelo Conejeros Rodriguez, Las Higueras Hospital
  • Ricardo Cartes Velásquez, Las Higueras Hospital
  • Nicolas Perez UTI, Las Higueras Hospital
  • Sonia Dalal, MD, Johns Hopkins University School of Medicine
  • Nkemdilim Mgbojikwe, MD, Fox Chase Cancer Center
  • Theodore Peng, MD, University of California, San Francisco School of Medicine

Current Projects:




Qualitative Review of Current Complex Case Management Practices



Partnership with Dr Mark Williams for PCORI Grant Examining Transitions Dependent on Payor Structure



Evaluation of VUMC Hospital at Home program



Evaluation of BWH Hospital at Home program