Christine Schaeffer, MD, medical director of Northwestern Medicine Transitional Care Clinic, describes the core components of its transitional care program. She also shares important considerations for health systems interested in implementing person-centered transitional care.

Primary care initiatives have shown that enhancing primary care can coordinate service delivery to the benefit of both patients and clinicians. In Medicare ACOs, primary care transformation has been foundational for shifting to a team-based approach that reaps benefits for everyone involved.

Caroline Morgan Berchuck, MD, describes a promising new complex care hospitalist model that aims to address this fragmentation and support people with complex needs in realizing better health outcomes.

Dr. Mark Prather, emergency physician and founder of Dispatch Health, shares how his organization provides on-demand home visits in 10 metropolitan areas and provided nearly visits to nearly 100,000 visits to patients last year.