# Hospital to Home: Optimizing Follow-Up After Discharge - Frankly Speaking Ep 472

An episode of [Frankly Speaking About Family Medicine](https://invisiblenetwork.ai/podcast/1194659367), 16 Feb 2026, 14 min.

Audio: https://mcdn.podbean.com/mf/web/nec7fphw9ew4p8cw/frankly-speaking-472-transitional-care.mp3

Credits: 0.25 AMA PRA Category 1 Credit™ CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-472 Overview: The transition from hospital to home is a valuable period for patients and clinicians. In this episode, we discuss which patients require follow-up, what should be reviewed during these appointments, and when follow-up should take place to help improve patient outcomes. Episode resource links: • Anderson, T. S., Herzig, S. J., Marcantonio, E. R., Yeh, R. W., Souza, J., & Landon, B. E. (2024, April). Medicare transitional care management program and changes in timely postdischarge follow-up. In JAMA Health Forum (Vol. 5, No. 4, pp. e240417-e240417). American Medical Association. • Anderson, T. S., Wilson, L. M., Wang, B. X., Steinman, M. A., Schonberg, M. A., Marcantonio, E. R., & Herzig, S. J. (2025). Medication Errors and Gaps in Medication Discharge Planning for Hospitalized Older Adults: A Prospective Cohort Study. Journal of general internal medicine, 1-10. • Balasubramanian, I., Andres, E. B., & Malhotra, C. (2025). Outpatient follow-up and 30-day readmissions: a systematic review and meta-analysis. JAMA Network Open, 8(11), e2541272-e2541272. Guest: Mariyan L. Montaque, DNP, FNP-BC Music Credit: Matthew Bugos Thoughts? Suggestions? Email us at FranklySpeaking@pri-med.com The views expressed in this podcast are those of Dr. Domino and his guests and do not necessarily reflect the views of Pri-Med.

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