Helping patients transition safely from hospital to home

Many people feel some relief when they’re discharged from the hospital. Yet the transition from hospital to home marks the beginning of a vulnerable period.

Patients may have to manage new medications and self-care routines, and they may not remember discharge instructions. Without adequate support, people can experience poor health outcomes or end up back in the hospital.

MultiCare’s population health team works with people newly discharged from the hospital in the South Sound region to support them through this transition, with the goal of reducing hospital readmissions and emergency department visits.

“The big success here is the creation of a reliable, evidence-based process that truly demonstrates safe passage for patients out of the hospital back into the community,” says Kari Steadman, MSN, RN, AVP of carelines. “It supports better outcomes and experiences for our patients, and it’s a process that can be replicated across the system.”

Bridging the gap

At the heart of the population health team are 17 ambulatory registered nurse (RN) care managers. Embedded in 17 of the 25 primary care clinics around the South Sound, RN care managers play a critical role in patient health, from helping people manage chronic diseases to creating action plans that drive improvements in quality of care.

RN care managers also take the lead on transitional care management — helping patients bridge the gap between hospital and home. Within two business days of discharge, care managers call patients. An important part of what they do is make sure those patients are connected with a primary care provider.

“A visit with primary care within seven days of discharge is the linchpin in optimal outcomes for patients,” Steadman says. “We’ve worked closely with outpatient and inpatient teams to ensure access and to get those appointments scheduled before patients even leave the hospital.”

In addition to ensuring patients have a primary care appointment scheduled, care managers also make sure patients’ needs are met and help troubleshoot problems.

“We help people solve transportation issues to make sure they can actually get to follow-up appointments,” says Jose Mari Lansang, MBA, BSN, RN, director of nursing for primary care & population health.

He continues, “We also catch medication errors or other safety concerns, clarify discharge instructions or identify missing referrals for services like home IV infusion. This helps prevent adverse events and ensures that what was intended upon a patient’s discharge is actually carried out.”

Perhaps one of the biggest gifts the population health team offers patients is peace of mind.

“We talked to one patient who was concerned that she’d had surgery on the wrong organ,” says Lansang. “The care manager who called her spent 45 minutes explaining the surgery, answering her questions and reassuring her that everything went as planned. Ultimately, this prevented a lot of emotional distress and an unnecessary ED visit.”

It’s all about relationships

A significant driver of this work is the Institute for Healthcare Improvement (IHI) Population Health Framework, which helps organizations chart a path toward practical, sustainable improvements in population health. MultiCare’s primary care clinics in the South Sound region have adopted this framework.

Lansang shares that it has helped the team strengthen its approach to transitional care management by standardizing processes, providing team trainings to ensure evidence-based practices are followed, and proactively initiating internal and external partnerships, among other improvements.

In 2025, the population health team helped more than 11,000 patients transition from the hospital back into the community, whether that was home or a skilled nursing facility.

One of the keys to the team’s success is relationships with community organizations.

“It’s all about relationship building, because as a health system we can’t do it all,” Lansang says. “We rely on our partners to provide services that we can’t — like homelessness support or food assistance. Our patients can’t heal or thrive after a hospital stay when their basic needs aren’t met.”

RN care managers establish relationships with community partners and refer patients with unmet needs to local organizations that are ideally positioned to step in and help.

What’s unique about the team’s approach to partnership is that they have incorporated nationwide best practices to create a blueprint for collaborating with community organizations — no matter where they’re located or what they do — to ensure the most meaningful impact for patients.

Some partners the team works with include Area Agencies on Aging and Aging and Disability Resource Centers.

Continuity through collaboration

The population health team’s efforts have produced results. The hospital readmission rate through September 2025 in the South Sound region was 6.9 percent, compared to 10.8 percent for those who were not part of the transitional care management process.

Another benefit has been the opportunity for continuous process improvement. Through this work, the team has uncovered ways to further support a smooth handoff between hospital and ambulatory (outpatient) services, such as confirming that after-visit and hospital-discharge summaries match and that patients get the education they need to provide self-care at home.

“We know that patients have better outcomes when health systems take a collaborative approach to creating continuity across inpatient and outpatient settings,” Steadman says. “We could not be successful in this work without our ongoing internal partnerships, particularly with hospital directors, case management leaders and their dedicated teams.”

As for what’s next, the population health team is looking to expand the scope of its community partnerships and share practices with teams across MultiCare.