brad and then carmella and then we will wrap up. >> a couple of points. around care coordination, we kind of talk about it but we sort of assume we're talking about coordinating care across space. geographically across settings. but to diane's point. care coordination in my experience, doesn't work unless you wrap together what happens in the hospital, what happens in the medical group, physician office and what happens at home. and community. it is possible, and there are models out there, that bring all of those together. that's the only way to deal with hospitalists who don't want people to come back again and again. they just have to deal with it when it happens. so care coordination across space is critical. unless it does that, it doesn't work. but care coordination across time is also important. meaning, and this goes back to joe newhouse's point, when you're well, why wouldn't you want to recover and do everything you can to do that? when you are super ill, your preferences change a lot. and tracking those preferences, documenting them, getting th