I've spent the past week as the attending physician on my residency program's adult inpatient service. Since the turn of the century, the rise of hospitalists and the corresponding decline in the number of office-based family physicians who provide inpatient care for their own patients has magnified the value of optimizing the handoff from hospital-based teams to primary care physicians . Chronic conditions that frequently lead to readmissions, such as heart failure, have been targets of transitional care interventions that may include self-care education, home visits, telephone contacts, and office visits. A 2014 Agency for Healthcare Research and Quality review found consistent evidence that high-intensity, multicomponent interventions for patients with heart failure reduced readmissions and mortality for 3 to 6 months after hospital discharge. Recognizing their potential to save money and improve outcomes, in 2013 the Centers for Medicare and Medicaid Services began all...