Standardizing Hospital to PCP Transitions

The Standard Transitions project aims to increase the consistency of transitions for individuals when they leave the hospital.  The project’s goal is to have hospitals use a similar discharge template to convey aftercare needs back to primary care providers in the community.  

When possible the transfer summary is conveyed via electronic data exchange to the identified primary care provider or patient centered primary care home, indicating to the provider that follow-up is necessary.  Upon receipt, participating provider organizations then reach out to the patient and ask a series of questions related to the patient’s health with a focus on how the patient is doing, whether the patient was prescribed new medications and how well the patient understands the dosage and frequency for taking these medications.  If concerns arise during this phone call a follow-up appointment is then scheduled to reconcile the medications or arrange for a timely care visit with the patient’s primary care team.  

This intervention is intended to reduce the number of costly hospital readmissions related to medication concerns, while also streamlining information sharing through the provision of a single template for primary care teams to understand their patients’ needs following a hospitalization.  Previously, primary care offices would receive discharge documentation from numerous hospital systems.  These documents frequently contained similar information in different order and physician offices were forced to use valuable time looking for critical discharge instructions.

With the enhanced process, primary care providers are spending less valuable time looking for the information they need and are able to spend more time providing care to their patients.


Current Status: This process has been implemented at all area Legacy and Providence hospitals, all Legacy and Providence primary care clinics and Multnomah County primary care clinics.  Oregon Health and Sciences University (OHSU) is exploring implementation, as are Adventist and Tuality hospitals.  Systems who have implemented this process are using it across all funding lines rather than focusing exclusively on Medicaid.

Contact information: Melinda Muller,