Thank you for your insightful comments regarding our trial. Frequently hospitalized patients are representative of one “final common pathway” for vulnerable patients in a fragmented healthcare system that does not adequately address health-related social needs. We agree that this is an area ripe both for future discovery and, particularly, effective interventions to address these important needs at both a health system and public policy level.

Though we agree that no single intervention will fix the problem of frequently hospitalized patients, there is more to be done in addressing the underlying risk factors for hospitalization and in measuring and improving patient-centered outcomes such as quality of life. A recent editorial promotes moving away from using readmissions as a hospital quality measure,1 which will hopefully lead toward a greater focus on interventions that improve patients’ lives across the continuum of care. In this population, these would include efforts to address social determinants of health, improve social support for patients living with chronic illness, and more robust interventions for patients living with chronic pain.