Figure 2.

Models for closing the gap. To address an outcome measure such as readmission requires arms of the health systems, which are often compartmentalized into silos, to overlap with common purpose. In answering, 5 key areas should be addressed: (1) defining the health jurisdiction from which most of the clients reside, (2) engagement of that community and its primary health infrastructure, (3) investing in technology to bring the gaps and address resource issues, (4) equipped for internal audits and aligning with partners to engage novel research, and (5) delivering these services at an acceptable cost.