In the current health care delivery system, care often seems fragmented, as though various providers and patients are all working in separate silos, with limited communication. The care any one provider delivers may be excellent, but without coordination among everyone involved in the process—and putting the patient and caregiver front and center—important details might be missed.

The results? More than 17 percent of Medicare beneficiaries are re-hospitalized within 30 days of discharge, and the Medicare Payment Advisory Commission estimates that up to 76 percent of these readmissions might be preventable. Not surprisingly, 64 percent receive no post-acute care between discharge and readmission.