1. Bourgoin, Angel PhD
  2. Balaban, Richard MD
  3. Hochman, Michael MD, MPH
  4. Greenwald, Jeffrey L. MD, SFHM
  5. Saluja, Sonali MD, MPH
  6. Palen, Ted E. PhD, MD
  7. Perfetto, Deborah PharmD
  8. Hogan, Eileen M. MPA
  9. Maxwell, James PhD


To understand current and idealized primary care-based care transition workflow processes for hospitalized patients, we conducted 133 interviews with staff at 9 primary care sites; community agency staff (n = 18); recently discharged patients (n = 33); and primary care thought leaders (n = 9). Current postdischarge workflows in primary care vary widely across settings, are often implemented inconsistently, and rarely involve communications with the patient or inpatient team during hospitalization. Based on these findings, we propose 5 principles for primary care practices to facilitate active involvement in postdischarge care, beginning during the hospital admission and extending until after the initial postdischarge primary care visit.