... circumstances of healthcare delivery; and the need to foster reflexivity, that is, self-improvement capacity, in healthcare organizations. Research limitations/implications Interventions to improve care coordination must be grounded in the reality of changing local circumstances and incentives for action...

.... Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health...