I am a clinician-investigator in the Division of Hospital Medicine at UCSF Health whose research focuses on making transitions across healthcare settings safer, more reliable, and more responsive to individual patients' needs. I study how clinical information, treatment plans, and responsibility for care are transferred across settings, and how failures in these processes contribute to adverse outcomes such as hospital readmission and mortality.

My primary research program focuses on older adults transitioning from skilled nursing facilities (SNFs) to home after hospitalization, particularly those with heart failure and other complex medical conditions. This program grew from my National Institutes of Health/National Heart, Lung, and Blood Institute K23 Career Development Award examining the transition from SNF to home following heart failure hospitalization and now encompasses questions about discharge strategy, clinical and functional readiness, information transfer, and outcomes after transition. My work examines how patients’ medical trajectories should inform the timing and processes of transition and how information needed for continued care can be reliably communicated across settings. I am particularly interested in how frailty, cognitive impairment, multimorbidity, and other sources of clinical complexity should inform individualized approaches to transitional care.

A central motivation for my work is that fragmentation in healthcare can shift the burden of coordination onto patients, caregivers, and clinicians assuming care in the next setting. When information or treatment plans do not reliably follow the patient, someone must reconstruct what happened, reconcile conflicting information, coordinate follow-up, and determine what should happen next. Patients with greater cognitive, functional, social, and financial resources may be better able to compensate for these failures, while those who are medically or socially vulnerable may be particularly exposed to their consequences. A safe transition should not depend on a patient's ability to compensate for weaknesses in the transition itself. My research seeks to identify and redesign systems-level processes so that information, treatment plans, and responsibility reliably follow patients across settings and high-quality care does not depend on patients, caregivers, or downstream clinicians repairing failures in healthcare delivery.