There is a growing gap between the population’s need for primary care services and the capacity of primary care to meet these needs. The number of retiring primary care physicians will soon surpass the number of physicians entering the primary care workforce (Bodenheimer & Bauer, 2016). The situation is exacerbated by the ever-expanding diverse, complex, and aging population that require advanced care coordination and transition management across the care continuum. These coordination and transition services will be vital for healthcare organizations seeking to achieve the Institute for Healthcare Improvement’s (IHI) Quadruple Aim: improving quality of care, improving the health of communities, reducing costs, and improving healthcare clinician work/life balance and job satisfaction (Institute for Healthcare Improvement, 2017).

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