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

Page: https://stenobird.com/podcast/frankly-speaking-about-family-medicine-434006/hospital-to-home-optimizing-follow-up-after-discharge-frankly-speaking-ep-472
Text version: https://stenobird.com/podcast/frankly-speaking-about-family-medicine-434006/hospital-to-home-optimizing-follow-up-after-discharge-frankly-speaking-ep-472.md
Podcast: [Frankly Speaking About Family Medicine](https://stenobird.com/podcast/frankly-speaking-about-family-medicine-434006)
Published: 2026-02-16T05:30:00+00:00
Episode link: https://primedfranklyspeaking.podbean.com/e/hospital-to-home-optimizing-follow-up-after-discharge-frankly-speaking-ep-472/
Audio file: https://mcdn.podbean.com/mf/web/nec7fphw9ew4p8cw/frankly-speaking-472-transitional-care.mp3
Processing state: not_requested
JSON: https://stenobird.com/v1/public/podcasts/frankly-speaking-about-family-medicine-434006/episodes/hospital-to-home-optimizing-follow-up-after-discharge-frankly-speaking-ep-472
Duration seconds: 862

## Resource

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.

## Actions

- request_transcript: `POST https://stenobird.com/v1/public/podcasts/frankly-speaking-about-family-medicine-434006/episodes/hospital-to-home-optimizing-follow-up-after-discharge-frankly-speaking-ep-472/transcription-requests` — Idempotently request low-priority transcript generation for this episode.
- read_markdown: `GET https://stenobird.com/podcast/frankly-speaking-about-family-medicine-434006/hospital-to-home-optimizing-follow-up-after-discharge-frankly-speaking-ep-472.md` — Read the agent-friendly Markdown representation of this episode resource.

A page view does not enqueue transcription. Agents should invoke `request_transcript` explicitly when they need this episode processed.

## Transcript

Full transcripts are not published on public pages unless there is a clear rights basis.