Bisognano M, Boutwell A. Frontiers of Health Services Management. 25(3):3-10.2009. http://www.ihi.org/resources/Pages/Publications/ImprovingTransitionstoReduceReadmissions.aspx. Accessed 8/13/14. Delivering high quality healthcare requires crucial contributions from many parts of the care continuum. However, as healthcare becomes increasingly specialized, corrdination between providers and between settings is to often not conducted as a team effort.