The Silo Next Door: Primary Care Leaders’ Perspectives On Collaborating with Hospitals During Hospital-to-Clinic Care Transitions in the Safety Net

Background: Poorly coordinated care between hospital and outpatient settings, and delayed access to primary care contributes to hospital readmissions. Given financial penalties for readmissions, hospitals are investing in interventions to improve care transitions following discharge. In parallel, Medicaid managed care organizations are providing incentives to primary care clinics to improve care coordination. Despite this, there is little collaboration between hospitals and primary care practices in efforts to improve care coordination following discharge. We sought to understand what primary care leaders perceived as barriers and facilitators to working with hospitals to improve patient transitions from acute inpatient hospital settings to outpatient care.