Transitioning patients between outpatient, inpatient, post-acute and home settings can be a major challenge for hospitals. For organizations participating in value-based reimbursement models, it can also be costly. This case study examines how Holyoke (Mass.) Medical Center redesigned its care management process to break down communication siloes across the care continuum and improve patient care. After six months, the efforts yielded measurable results, including improved patient experience scores and reduced readmissions based on an analysis by Press Ganey.