Current care models and delivery systems frequently fail to meet the needs of high-risk older patients. Medicare beneficiaries with multiple comorbid conditions often receive poorly coordinated care, leading to frequent hospital and emergency department visits, increased rates of readmissions, and suboptimal outcomes.

Improving care for high-risk older patients has been an area of health care system and policy-maker attention for nearly 2 decades. Despite widespread use, outpatient care management interventions focusing on care coordination, medication adherence, and self-management have produced mixed results. Within this population, programs focusing on transitions among inpatient, postacute, and community sites of care are often more successful. For example, the transitional care model at the University of Pennsylvania successfully reduced inpatient utilization and improved select outcomes, such as readmissions, hospital days, and charges for health care services. However, replication and widespread adoption of these and other related programs have failed—adding another layer of care simultaneously addresses and undermines time-sensitive coordination and cooperation among hospital teams, patients, in-home caregivers, and primary care clinicians.

But what if delivery models were redesigned to eliminate the discontinuity between inpatient and outpatient settings? Doing so may create a powerful new lever for improving quality and reducing costs and potentially obviate the need for additional layers of transitional and care management service. In this Viewpoint, we explore 2 emerging delivery models focused on integrating inpatient and outpatient management for high-risk older patients.