The Clinician is the Customer

What if one of the most important moments in healthcare happens after a patient leaves the hospital? In this episode of PEMBA On Demand, Dr. Norman Chapin sits down with Dr. Tiffany Hanf, Regional Medical Director for Post-Acute Care at TeamHealth and current PEMBA student, to discuss one of healthcare’s most persistent and costly challenges: helping patients successfully transition from the hospital to post-acute care while reducing preventable readmissions.

Dr. Hanf oversees post-acute care operations across nine western states and shares insights from her work leading skilled nursing facilities, long-term care facilities, and rehabilitation programs. At the center of the conversation is her work on an acute-to-post-acute transition program designed to improve coordination, communication, and continuity of care between hospitals and post-acute providers.

She explains that one of the biggest barriers to successful transitions is the fragmentation that often exists between hospitals and post-acute facilities. Because these organizations are frequently managed by separate entities, critical information can be lost during the handoff process. Effective discharge summaries, medication coordination, and timely communication are essential to ensuring patients receive seamless care after leaving the hospital.

The discussion explores how the role of physicians in post-acute care has evolved significantly over the years. Dr. Hanf explains that modern post-acute medicine requires dedicated physician leadership, advanced practice clinicians, structured rounding models, and specialty support services. The traditional model of infrequent physician visits to nursing facilities has largely been replaced by a more proactive, team-based approach focused on quality outcomes and reducing unnecessary hospitalizations.

Dr. Hanf also shares lessons from a collaborative initiative with a health system seeking to address long hospital stays, discharge bottlenecks, and readmissions. Through coordinated partnerships and standardized workflows, her team has demonstrated improvements in transitions of care, reductions in readmissions, and shorter hospital lengths of stay. However, she notes that meaningful change often requires overcoming organizational silos and building trust among multiple stakeholders.

A significant portion of the conversation focuses on readmissions from post-acute care settings. Dr. Hanf explains that many readmissions are driven by factors such as infections,