Problem
As disjointed as outpatient care may seem in itself, an area of particular concern is the transition of outpatients to an inpatient status, and back after hospital discharge. The balkanization of care has led to significant "silo" effects where the patient arriving in the hospital may have been in an entirely different health care system as an outpatient, with the same effect occurring when that patient is discharged from a complicated hospital course back to an outpatient environment which may be entirely unaware of that inpatient episode.
In broad terms, how can we improve this?