In this first episode of the Systems in Action series, hosts Jennie Adams and Dr. Ami DeWaters explore one of the most critical — and fragile — moments in healthcare: care transitions. From the emergency department to the inpatient floor, and from one clinical team to another, transitions are high-stakes for patients and high-pressure for clinicians.

Joined by guest Dr. Brian McGillen, hospitalist and Medical Director of Care Transitions at Penn State Health, the hosts discuss why care transitions so often break down in real clinical practice. Drawing on frontline experience, they examine common communication pitfalls, workflow pressures, and human factors that shape handoffs — even when everyone is working hard and acting in good faith.

This conversation sets the stage for the Systems in Action: Care Transitions learning package, which pairs this podcast with a dramatized handoff video, facilitator guide, and learner materials designed to support systems-based learning across UME, GME, and faculty development.

Intro song I'm being led away LDcc written by Kira Daly accessed through the Free Music Archive and licensed under a Attribution 4.0 International License.

What does it really take to keep a patient’s care connected?

In this episode of Systems in Action, hosts Jennie Adams and Dr. Ami DeWaters talk with Dr. Cynthia Chuang, Professor of Medicine and Public Health Sciences and Associate Director for Research in the Division of General Internal Medicine at Penn State College of Medicine.

Drawing on Dr. Chuang’s experience as a general internist, primary care physician, and health services researcher, the conversation explores coordination of care from the primary care perspective. We discuss the often-unseen work required to connect care across specialists, tests, referrals, hospital encounters, and follow-up; the access and system barriers that can make coordination difficult; and what happens when information or responsibility falls through the cracks.