Patients returning to the community after surgery often experience a disconnect when transitioning from hospital to community home care. Many receive little organized/planned care following discharge sometimes resulting in unplanned expensive care in hospital emergency departments and inpatient readmissions. Trillium Health Partners, a large community/teaching hospital, in partnership with community care provider Saint Elizabeth Health Care, designed and implemented a seamless "bundled care program" for cardiac surgery patients extending from hospitalization to 30 days after discharge. With a risk/gain sharing model, the bundled care program enabled a novel integrated clinical patient care model. This included integrated care coordinators embedded within the hospital team, 24/7 patient phone line, integrated medical records and a tracking board that enabled performance monitoring and improvement. Evaluation results revealed: a 16% reduction in post-operative length of stay; a 38% reduction in readmission rates; and a 13% decrease in total system cost per patient, together with markers of improved patient experience.