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Home > Webinars
Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, a 45-minute webinar on February 26, 2015, now available for replay
Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, a 45-minute webinar on February 26, 2015, now available for replay
Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, a 45-minute webinar on February 26, 2015, now available for replay
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A Care Transitions Task Force at San Francisco General Hospital (SFGH) was charged in 2012 with developing a multi-disciplinarian, cross-continuum approach to improving care transitions...not an easy task for an organization that had previously operated with a siloed approach by each hospital service.

The Task Force created a central clearinghouse of all care transition efforts, hired an analyst to create a dashboard to monitor improvements in care transitions and standardized its care transition efforts across the organization as a whole and has begun reporting impressive results even while serving as the public safety net hospital in San Francisco and as the only trauma hospital in that city.

During Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, a February 26th webinar, now available for replay, Dr. Michelle Schneidermann, associate clinical professor of medicine for the division of hospital medicine at University of California San Francisco/SFGH and medical director of the San Francisco Department of Public Health Medical Respite and Sobering Center, shares the key achievements of the Care Transitions Task Force and its impact on readmission rates.

You will learn:

  • How the care transitions dashboard was used to engage leadership and front line clinical staff to drive care transition improvements;
  • The standardized approach to care transitions used across the hospital for all patient discharges;
  • The roles of primary care practices and a post-discharge bridge clinic in the care transition process;
  • How SFGH meets the unique challenges of transitioning homeless patients, heart failure patients, and high-utilizers; and
  • The stratification criteria for telephonic versus home visit patient follow-up.

Have questions on our webinar formats? Visit our webinar FAQ.

You can attend this program right in your office and enjoy significant savings — no travel time or hassle; no hotel expenses. It's so convenient! Invite your staff members to gather around a conference table to listen to the conference.


Presidents/CEOs/CFOs, medical directors, quality improvement executives, physician executives, health plan executives, disease management executives, population health management managers, care coordinators and strategic planning directors and consultants.


Dr. Michelle Schneidermann completed her primary care internal medicine training at UCSF and joined the UCSF faculty in 2003, where she is a member of the Division of Hospital Medicine at San Francisco General Hospital (SFGH). Through her inpatient clinical work and work with ambulatory programs, she has been able to directly witness the successes and challenges of patients’ transitions and generate feedback to the providers and systems that manage their care.

At SFGH, Dr. Schneidermann leads the Care Transitions Taskforce, a cross-continuum, multidisciplinary team charged with improving the quality and safety of care transitions as well as reducing preventable readmissions. She is involved in designing, implementing, and evaluating a variety of care transitions projects including an intervention based on elements of Project Red, targeting multicultural and limited English speaking seniors. She also serves on the governing board of the CMS funded Community Care Transitions Program awarded to the San Francisco community to help improve care transitions city-wide.

As the Medical Director of San Francisco’s Medical Respite and Sobering Center, she works with the Department of Public Health and a wonderfully talented and committed staff to provide transitional and recuperative care for discharged homeless patients. Dr. Schneidermann works on strategic planning and quality improvement processes and collaborates with other respite sites across the country to gather and evaluate data that may influence national policy and reimbursement for respite services.

Publication Date: February 26, 2015
Number of Pages: 45-minute webinar
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