Inventions to improve care transitions and reduce hospital readmissions must be patient-centered and address social determinants in addition to medical needs so patients can stay in their homes. Patient-centered care focuses on the patient's physical comforts and emotional well-being (NEJM Catalyst). Social determinants of health are the conditions in which people are born, grow, live, work and age and include factors like physical environment, social support, and access to healthcare (WHO).