Autumn has always been one of my favorite seasons.  The transition between summer and winter brings bountiful harvests and beautiful colors.

But not all transitions are as lovely as those we experience this time of year.

Care coordination is one of the most important things we do in primary care, but so much of it is either a paradigm shift or just very difficult to accomplish.  Care coordination is managing any transition in healthcare.  Doing care coordination effectively requires not only a system change, but many times, a culture change.  We have been living in world where, traditionally, how much we do matters more than the outcome of all of those efforts.  The fact that we “told that patient to go to the cardiologist” or “told them to take their medication but they refused” no longer is enough for legal guidelines nor for reimbursement requirements.

There are myriad ways we transition patients.  Sometimes it is from one setting to another, via referral to a specialist or exchanging information with hospitals.  One thing payers are really paying attention to are transitions from primary care to hospitals back to primary care.  It can also be life stage changes-transitioning from pediatric care to family practice, family practice to internal medicine, or internal medicine to long term care.  Sometimes it seems like a micro level change-change in medications or reconciling medications from other healthcare practitioners-but even these seemingly small transitions can have a big impact for patients and families.

I am by no means a betting woman, but I would put money on you being able to think of a loved one who has experienced an uncomfortable, inconvenient, or disastrous transition.  A family member who received the wrong medication, dose, or duplicate medication therapy due to inconsistent provider records.  One who receives screening for something serious (depression, domestic violence) but no follow up or actual intervention.  Or particularly painful, watching a loved one die a painful, undignified, and drawn out death because her advanced directive was flagrantly disregarded.

For a number of years, we have been bombarded with various expectations—and to be quite honest, some of them are absolutely ridiculous and make no improvement in a patient’s care.  Others—when you look at the intent of the requirements around care coordination and how it affects our care, our health, and our lives—should make us pause.  If you are in an ACO or managed care arrangement, you are probably more aware of the cost of not appropriately following up on a hospitalization, or how much a Medication Related Problem will eat away at shared savings.

Regardless of regulations and requirements, if you have been party to one of the ugly transitions I mentioned above, or another similar situation, you understand why we are being able to raise the bar when it comes to care coordination.  Which is one reason I am excited to be part of AIMM.

AIMM, thanks to support from the Cardinal Health Foundation, is facilitating the E3 Learning Collaborative to help thirteen organizations strengthen their own care transition process.  Similar to other team cohorts, and true to AIMM’s signature style, teams are participating in all teach, all learn events highlighting best practices in effective team building, leadership, data and quality improvement.  These elements help organizations not only avoid these ugly transitions, but improve all aspects of the triple aim: patient experience, population health, and decreased cost of care.

Organizations or partners interested in being part of the AIMM experience may contact AIMM at

Learn more about AIMM’s current partnerships.


Chris Espersen, MSPH
AIMM Learning Coach