Background: Compared with health care systems globally, the U.S. health care system expends more resources yet achieves worse patient outcomes. Growing recognition that such low-value care is a system-level problem has spurred efforts to optimize system-level processes. Low-value hospital admissions are a major contributor to overall low-value care, but limited descriptions of specific processes for [...]

Background: Unplanned readmissions in the U.S. healthcare system cost over $15 billion annually, a burden that increasingly impacts health systems as more patients transition to fully capitated models [1-2]. Despite evidence supporting the protective effect of post-hospitalization visits with primary care providers (PCPs), patient completion rates of these visits remain low [3-5]. Barriers include provider [...]