The hospital-to-home transition can be treacherous

Clearing a path for cardiac patients, providers and payers

Alex Markowits
3 min readOct 14, 2020


Solving problems has driven Spring Hills’ growth since our founding 20 years ago. When we saw senior living communities that could be helped by our experience and expertise, we welcomed them into our system. This is how we have expanded from one assisted living facility in New Jersey to 28 communities across seven states. When we saw gaps in the services that people across our regions needed, we filled them. This is why we created better, more engaging memory care programs, home care services, and post-acute care services.

This dedication to finding solutions for the troubles facing the people and places we serve has defined us and united our team for two decades — and will continue to shape how we evolve into the future.

Now, our team is tackling one of the greatest challenges in our health care system: transition of care. The transition from hospital to home is difficult for many under the best of circumstances. When this transition is paired with recovery from a major medical event like a heart attack, it can be incredibly trying. Step-down care can sometimes be insufficient, and discharge plans confusing and hard to follow. This often leads to unfollowed doctors’ orders, missed appointments, unfilled prescriptions, and unfortunately, readmission to the hospital.

Our team saw this dynamic play out in some of our communities, and we heard from physicians, health systems and health plan partners about their frustrations and concerns. We set out to solve the problem, and the idea for the Spring Hills Cardiac Program was born.

We knew our cardiac program needed to do more than prevent heart failure or keep patients in a safe holding pattern. It needed to provide a customized care plan for every patient, exceptional clinical expertise and oversight, and the support required for a real shot at improving the patient’s health and quality of life. For provider and payer partners, the program had to be reliable, accountable, and a money saver. The program had to have real, measurable value propositions for patients and their caregivers, doctors, hospitals, and insurers.

The Spring Hills Cardiac Program is the first of several condition-specific programs that we are planning to develop. It is truly comprehensive, providing far more than standard heart failure programs. We have invested in the infrastructure, technology, and expertise to provide heart patients hospital-quality care in a more comfortable setting. This means that even high-acuity patients can be discharged earlier from the hospital and transferred safely to Spring Hills, reducing expenses for both provider and payer. Our multidisciplinary clinical teams establish relationships with patients and their families before hospital discharge to facilitate the move to Spring Hills, where the patient will have more clinical oversight, proactive monitoring, and coordinated communication than anywhere else.

We use advanced technologies — typically only available in a hospital — to provide real-time data for our on-site cardiologist. This has life-saving implications. For example, data we collect can identify if a patient is septic 32 hours before a blood test can. Once the patient is ready to head home, our Spring Hills Population Health team takes over.

We cannot yet say that we have solved this transition of care problem entirely, but early results of our cardiac program are promising. Twenty years of post-acute and long-term care experience, combined with the expertise of clinicians, heart specialists, and population health management and data analytics experts, allows us to deliver unmatched cardiac care. Our goal is to support recovery from a hospital stay, reduce chances of post-discharge complications and readmission, and provide a path to better health.



Alex Markowits

Founder & President/CEO, Spring Hills. Realizing a vision for health care built on innovative partnerships and integrated support systems.