A patient may leave the hospital medically stable, but that does not always mean recovery is secure.
For patients moving from the hospital to a skilled nursing facility or another post-acute setting, the first 24 hours can be a critical window. Medication changes must be understood. Rehabilitation goals need to be clear. Follow-up appointments must be coordinated. And the care team needs to know what to do if the patient starts to decline.
Matthew Cowling, DO, chief clinical officer at Medrina, described the transition from hospital to post-acute care as a relay race. The hospital team may run an excellent first leg, he said, but the race can still be lost if the baton is dropped during the handoff.
That baton includes medication reconciliation, functional status, rehabilitation goals, risk factors and recovery ownership, according to a presentation during the AMA Insight Network Summit by Dr. Cowling and Sandeep Pulimi, MD, a physician leader at Medrina. Too often, the patient arrives at the skilled nursing facility, but the recovery plan does not fully arrive with them.
“Focusing on the first 24 hours has been a big game changer for us,” Dr. Cowling said. “In terms of the physician oversight in the systems that we use, we try to take the fragmentation out the best we can. There are multiple ways to do that.”
Medrina is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Treat discharge as the start
In many cases, hospital discharge is treated as a finish line. But for patients with complex medical needs, it is often the start of another vulnerable phase.
Medrina’s physician-led recovery model is built around that idea. The model emphasizes early physician involvement, warm handoffs, rehabilitation coordination, interdisciplinary alignment and clear escalation pathways when a patient’s condition changes.
The goal is to prevent a successful hospitalization from becoming what Dr. Cowling called a “medical success but a functional failure.” A patient may no longer need hospital-level care, but still may be unable to climb stairs, safely manage medications, attend follow-up visits or function independently at home.
That gap matters because functional decline can lead to falls, readmissions, longer stays, higher use of healthcare services and failure to return home.
“We really view functional recovery as a true medical outcome for the patient,” Dr. Cowling said.
See patients quickly
Medrina’s model focuses on seeing patients soon after they arrive in post-acute care. In partnership with Northwestern Medicine, Dr. Pulimi said Medrina physicians are connected to patients before they arrive at participating post-acute sites. That gives physicians access to information from the hospital team and helps them understand the plan before the patient reaches the facility.
Once the patient arrives, Medrina physicians see them face to face within 24 hours, Dr. Pulimi said. That first evaluation includes medication reconciliation, review of follow-up needs and an assessment of the patient’s medical and functional status. Within 36–48 hours, the care team develops an initial care plan so patients and families understand what comes next.
That timing is important because delays can allow problems to grow. A missed medication change, unclear therapy goal or lack of follow-up may seem small at first. But each can alter a patient’s recovery trajectory.
Dr. Cowling said he has unfortunately seen patients in skilled nursing facilities after they have already began to decline.
“A lot of times by the time we intervene, it’s too late,” he said. “Early Intervention is key to success.”
Make the handoff stronger
Transitions of care are a known weak point in the healthcare system. Patients may move from one site to another, but the information needed to continue recovery may not move cleanly with them.
Drs. Cowling and Pulimi identified several common transition failures:
- Incomplete handoffs.
- Delayed physician evaluation.
- Gaps in medication reconciliation.
- Missing functional context.
- Unclear escalation pathways.
These breakdowns can contribute to avoidable readmissions, prolonged length of stay, throughput problems and higher total cost of care.
For that reason, Dr. Cowling said the handoff is one of the strongest places to intervene, noting that “the transition of care is where we’re really trying to focus as a company.”
In practice, that means clarifying the hospital plan before the patient arrives, identifying medication changes, understanding the patient’s functional baseline and making sure physicians know when and how to escalate care.
Dr. Pulimi said communication with the emergency department also matters. If a patient needs to be sent back for a focused issue, such as a blood transfusion, the post-acute physician can call ahead and explain the reason for transfer. That can help the emergency department understand what is needed and what can be managed in the post-acute setting.
Put physicians at the center
Medrina describes its approach as physician-led, but not physician-only. Depending on the market, the model may involve physiatrists, hospitalists, pulmonologists, cardiologists and advanced practice providers. The core idea is that a physician remains at the center of the patient’s recovery plan, with support from nurses, therapists, care coordinators and other health professionals.
Physical medicine and rehabilitation physicians, or physiatrists, play a key role because their specialty focuses on restoring function after illness or injury. In the presentation, Dr. Cowling described function as the “organ system” of physiatry.
That lens changes the question after discharge. Instead of asking only whether the patient is medically stable, the team also asks whether the patient is on a safe recovery path.
As Drs. Cowling and Pulimi put it: “The next phase of healthcare delivery is not simply disease management. It is recovery management.”
Use data to find risk earlier
Medrina’s model also uses EHR integration, functional assessments, care coordination information and predictive analytics to identify patients whose recovery may be veering off course. The point is not to replace physician judgment. It is to give physicians better visibility into risk.
Drs. Cowling and Pulimi framed readmissions as a lagging indicator. By the time a patient returns to the hospital, functional decline may have started days earlier. Better recovery intelligence may help physicians and care teams intervene before that decline leads to a crisis.
Still, Dr. Cowling acknowledged that EHR integration remains difficult. Different hospital systems share data in different ways, and even when information can be pulled into another system, workflows may require physicians and care teams to document in more than one place.
“The biggest issue with this is data acquisition and the ability to gather it all in the same place “Dr. Cowling noted.
Measure recovery continuity
Drs. Cowling and Pulimi also cited a matched-cohort analysis comparing Medrina patients with similar-risk Medicare beneficiaries. The analysis found 38% lower medical readmissions, 9.5% lower total cost of care, 44% fewer skilled nursing facility days per 1,000 and a 16% shorter skilled nursing facility length of stay among Medrina patients.
Those findings should be interpreted as Medrina-reported results from a matched-risk analysis, not as proof that one intervention alone caused the differences. But they point to the larger argument behind the model: Recovery continuity may change what happens after hospitalization.
Together, Drs. Cowling and Pulimi contrasted a traditional focus on acute stabilization, discharge completion and reactive readmission management with an emerging focus on recovery continuity, functional recovery optimization and physician-led post-acute integration.
In other words, health systems are increasingly accountable not only for whether a patient leaves the hospital, but also for whether that patient safely continues to recover.
