We have a saying in the Military: “Slow is Smooth, Smooth is Fast.”
The adage captures a powerful truth about precision under pressure: deliberate, well-orchestrated actions—even if seemingly slower—often yield faster, more effective outcomes. This principle holds particular relevance in healthcare, especially in the vulnerable moments of patient handoffs—whether it’s shift changes, discharges, or transfers between care settings. These transitions are high-risk junctures where fragmented communication, ambiguous accountability, or overlooked social needs can lead to missed follow-ups, medication errors, and preventable emergency department (ED) visits and readmissions.
For ACO leaders—whether independent or health system-affiliated—mastering transitions of care is not just a clinical imperative, it’s a strategic one. Building workflows that prioritize clarity, empathy, and real-time coordination enables smoother handoffs and ensures patients don’t fall through the cracks. Like the military, investing in processes that feel slower on the front end—like structured discharge planning or warm handoffs to post-acute providers—can dramatically accelerate downstream outcomes, improving quality, reducing costs, and enhancing patient experience across the continuum!
The breakdown often starts with well-intentioned but inconsistent processes. A nurse near the end of shift might conduct a rushed bedside report, omitting key social risk factors like food insecurity or caregiver support. A hospitalist may discharge a patient before a follow-up appointment is secured, or discharge instructions might be uploaded to the EHR but never flagged or reviewed by the patient’s primary care team in time to intervene. Meanwhile, the patient—confused by medical jargon and unable to fill a prescription due to transportation barriers—ends up back in the ED. These aren’t isolated missteps; they are symptoms of systemic friction in how information flows, how accountability is shared, and how “going through the motions” often leaves the human experience of care overlooked in the handoff process.
Incorporating the human element into process improvement is essential. Every patient transition involves a series of decisions made by people under pressure— physicians, nurses, care managers, social workers, caregivers. Standardizing workflows can reduce variability, but lasting improvement comes when frontline teams are engaged as problem-solvers. Successful ACOs apply “top-down planning and bottom-up refinement” (another military adage), where leadership defines goals and structures while teams on the ground iterate, personalize, and optimize processes based on real-life complexity and patient needs.
A “crawl, walk, run” framework offers a practical roadmap:
Crawl: Build Awareness and Consistency
Start by identifying where transitions most often fail. Are patients receiving follow-up appointments before discharge? Are ED visits flagged for care management outreach? Basic fixes—like structured discharge checklists, shared care plans, or automated appointment scheduling—can dramatically reduce failure points. At this stage, begin integrating social determinants of health (SDoH) into discharge planning by screening for housing, food access, and transportation needs in addition to standard procedures like medication reconciliation, etc.
Walk: Connect Teams, Technology, and Patients
As consistency improves, invest in tools that enable real-time care coordination. Use ADT (admit-discharge-transfer) feeds to alert ACO care managers of hospital events. Employ digital platforms like chronic care management (CCM), remote patient monitoring (RPM), and care navigator tools to capture symptoms, monitor patients, send follow-up reminders, and connect patients with their primary care physician (PCP). Embed care coordinators in inpatient units and establish direct communication channels with primary and post-acute providers aiding in the transitional care management (TCM) process. Begin using data and analytics to risk-stratify patients and prioritize interventions for those most vulnerable to readmission or avoidable ED use.
Run: Optimize and Personalize Transitions
In the mature stage, transitions are not just safer—they’re proactive, personalized, and tech-enabled. Use virtual care to remove access barriers. Equip care teams with dashboards that integrate medical, behavioral, and social risk factors. Engage community-based organizations (CBO) to close gaps in care plans—like connecting food-insecure patients to local pantries or arranging home visits for patients with mobility limitations. These interventions are grounded in empathy but powered by data where human-centered design meets real-time intelligence.
Take the example of a patient with COPD and limited health literacy. A high-functioning transition plan begins with bedside education using teach-back (back-brief in the military), followed by an alert to a care coordinator who arranges a virtual check-in the next morning. The patient receives a digital inhaler with remote monitoring, and a community health worker ensures medication access and connects them to a smoking cessation group. Each touchpoint is intentional—and though it may appear slow, the process is smooth, coordinated, and ultimately faster in preventing deterioration while reducing cost.
In conclusion, smooth transitions aren’t about moving faster, they’re about moving smarter. ACOs that embrace deliberate planning, invest in scalable process improvement, and engage both people and technology will reduce ED visits, prevent readmissions, and drive the outcomes that matter most. The most successful organizations blend strategy with empathy, analytics with action, and precision with partnership. When transitions are seamless, and every role is clear, the system runs better—even when it starts by slowing things down.
“Slow is Smooth, Smooth is Fast”
If you have questions or would like to discuss ways to improve your TCM process, please contact our strategy & value-based care team here at Pinnacle.
