Every patient journey within the healthcare system is unique and it takes a team to care for that patient. By mapping the touchpoints for our patients’ journey and identifying the value chain, we have identified areas that will allow us to attain a seamless continuum of care for our patient population. The coordination between the various services of primary care, palliative care, mental health and community care will allow for an organic team approach that will be enhanced by house calls, after hours services and eVisits.