Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions

The objective of this study is to design and implement a set of procedures (the intervention) to improve patients\' experiences when they are discharged home from the hospital. Second, this study aims to look at how the intervention affects problems that are known to occur after discharge, including medication issues, worsening medical problems, or readmission to the hospital. The investigators will study how well patients recover the ability to do the things they could before they were admitted to the hospital and their opinions of the discharge process. Lastly, this study will look to understand the best way to implement the intervention into different hospitals and practices, and which types of patients benefit from it most.