Background: Poor coordination between hospital and outpatient care worsens health outcomes, and increases preventable hospitalization and health care expenditures, especially for socioeconomically disadvantaged populations. Evidence of the effects of current programs to improve care coordination is mixed, and there is little data on how their impact may differ for hospitalizations for ambulatory care-sensitive conditions (ACSCs) [...]

Background: High health care costs and poor outcomes are associated with high hospitalization rates and are concentrated in a small fraction of the population. Fragmented patient care and socioeconomic disadvantage may further increase hospitalization rates. To defragment medical care for a socioeconomically diverse population of Medicare patients at increased risk of hospitalization, the University of [...]

Background: Poor coordination between hospital and outpatient care worsens health outcomes, and increases preventable hospitalization and health care expenditures, especially for socioeconomically disadvantaged populations. Evidence of the effects of current programs to improve care coordination is mixed, and there is little data on how their impact may differ for hospitalizations for ambulatory care-sensitive conditions (ACSCs) [...]