Microtransitions: A Crevice in the Bridge Before It Cracks

Mrs. P is an 82-year-old retired farmer’s wife, functionally independent at baseline, who was admitted to post-acute care services at a skilled nursing facility for debility after a seven-day hospital stay for acute exacerbation of her chronic systolic and diastolic heart failure. Her rehabilitation stay was complicated by a weight gain of five pounds in the first week. Her follow-up evaluation at the heart failure clinic (one week after her hospital discharge) recommended intravenous furosemide, for which she was directly transferred to the heart failure clinic’s outpatient infusion center.