With 25 years of experience, the charter sector has had enough time to experience a host of unanticipated and unresolved problems related to the complex ways in which charter school governance relates to school leadership. The time has come for the sector to revisit some fundamental decisions about how charter schools and networks are governed, both to tighten arrangements that are excessively loose and to encourage further innovation. The future of chartering should not be a linear extension of the past. If we left some problems unsolved in 1991 (or had no idea that they would become problems), that is no reason not to take stock of things as they stand today and to set matters right before moving forward. This article is based on the authors’ book, Charter Schools at the Crossroads: Predicaments, Paradoxes, Possibilities (Harvard Education Press, 2016).

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Objectives Many patients with congenital heart disease (CHD) are lost to cardiology follow-up, but may continue to receive care from other clinics or facilities in the same health system. We analyzed receipt of care at other locations within a single rural academic health system after loss to follow-up in a pediatric cardiology clinic. Material and methods Patients with CHD seen in the clinic during 2018 and subsequently lost to cardiology follow-up were included in the study. Subsequent visits to other locations, including other subspecialty clinics, primary care clinics, the emergency department (ED), and the hospital, were tracked through 2020. Results Of 235 patients (median age 7 years, 136/99 female/male), 96 (41%) were seen elsewhere in the health system after loss to cardiology follow-up, most commonly by other subspecialty clinics or in the ED. Patients with medical comorbidities, Medicaid insurance, and those living closer to the clinic were most likely to continue receiving care within the same health system. Conclusions Patients with CHD are frequently lost to cardiology follow-up. Our study supports collaboration across specialties and between cardiology clinics and affiliated EDs to identify patients with CHD who have been lost to cardiology follow-up but remain in contact with the health system. A combination of in-person and remote outreach to these patients may help them re-establish cardiology care.