The goal of this pragmatic clinical trial is to learn if it is possible to implement a Primary Hospital Provider (PHP) team that aims to improve continuity of care for patients who are frequently hospitalized. The main question it aims to answer is: Are patients assigned to the PHP team more likely to be assigned to this team during a follow up hospitalization? Researchers will compare this to similar patients assigned to receive usual care. Some patient participants (or their caregivers) from both the PHP team and usual care groups will be asked to participate in interviews to help researchers understand the needs of patients who are frequently admitted and the care they receive.
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Number of patients readmitted to the PHP team
Timeframe: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Number of patients readmitted to usual care team
Timeframe: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Percentage of patients readmitted to the PHP team
Timeframe: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Percentage of patients readmitted to usual care team
Timeframe: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months