2025 Imagine - W21 - From Discharge to Follow-Up: Closing Gaps in Care Transitions - On Demand
Learn how two organizations improved postdischarge follow-up and reduced readmissions by using data and collaborative approaches to care. UCLA Health’s learning system approach aligns multidisciplinary teams to track interventions and outcomes over time, leading to measurable gains in care transitions. In parallel, a heart failure initiative from University of South Florida Tampa General Physicians focuses on patient engagement, care coordination and standardized follow-up within seven days of discharge — showing marked improvement in visit adherence and reduced admissions. Together, these efforts offer a road map for building sustainable, data-informed approaches to timely postdischarge care across patient populations.
Target Audience
- Dietitians
- Nurses
- Pharmacists
- Pharmacy Technicians
- Physicians
- Physician Associates
- Healthcare Quality Professionals
- Other Healthcare Professionals
Learning Objectives
- Describe a data-driven learning system approach for improving care transitions.
- Outline a standardized framework for heart failure patients to improve hospital follow-up rates within seven days.
Wendy Simon, MD, CPHQ, Medical Director, Inpatient Quality, Department of Medicine Quality Team, UCLA Health, Los Angeles, Calif.
Brian Le, MPH, CPHQ, Program Manager, UCLA Health, Los Angeles, Calif.
Terri Ashmeade, MD, MSMS, CLSSBB, Vice President of Medical Affairs, USFTGP and Chief Medical Officer & Vice Dean for Clinical Affairs, USF Health MCOM, University of South Florida Tampa General Physicians (USFTGP), Tampa, Fla.
Christine Hutchinson, BSN, RN, AMB-BC, Director of Quality, Patient Safety, & Population Health, University of South Florida Tampa General Physicians (USFTGP), Tampa, Fla.
Ella Elizee, APRN, FNP-C, MBA, CCDS, Manager - Population Health Department, University of South Florida Tampa General Physicians (USFTGP), Tampa, Fla.
Joint Accreditation Statement
In support of improving patient care, Vizient, Inc. is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

The Commission on Dietetic Registration (CDR) accepts nutrition-and-dietetics-related continuing education credits from Jointly Accredited Providers. After completing this activity, CDR-credentialed practitioners may claim CPEUS under Activity Type 102; 1 contact hour (60 minutes) = 1 CPEU.
Available Credit
- 0.75 AAPA CMEVizient Inc. has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria.
- 0.75 ACPE Pharmacist
- 0.75 ACPE Pharmacy Technician
- 0.75 AMA PRA Category 1 Credit™
- 0.75 ANCC
- 0.75 CDR
- 0.75 CPHQ – Certified Professional Healthcare Quality
- 0.75 General CE - Attendance
Select the “Obtain Credit” button to access the session evaluation and to claim CE Credit.
Please Note:
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- Please click here to enter the code you received at the end of the session to verify your attendance if you have not already done so: https://continuingeducation.vizientinc.com/code
Required Hardware/software
The Vizient CE Learner Portal is compatible with most modern web browsers (such as Firefox, Google Chrome, Microsoft Edge, Apple Safari) and can also be accessed with mobile devices.

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