Patients discharged from U.S. hospitals return far too often. Almost one in five elderly patients released from a hospital is back within 30 days, and more than one in three are back within 90 days. Although some readmissions are part of a patient’s treatment plan, many are avoidable. They are the result of a fragmented system of care that too often leaves discharged patients confused about how to care for themselves at home, unable to follow instructions they didn’t understand, not taking medications properly or getting the necessary follow-up care, and ultimately leading them to return to the hospital. These unnecessary readmissions negatively affect patients’ health, place a burden on their families and caregivers, and cost our country billions of dollars.