Health care in the U.S. is fragmented and disorganized. Policy experts for years have sought ways to remedy the problem through coordination and integration of care. On the national level results have been disappointing. Only an exceptional few local systems have been able to pull it off effectively. These are worth looking at. One example is Wisconsin-based Gundersen Health, recently profiled in Mayo Clinic Proceedings.
To get a visceral appreciation for the culture needed to have integrated health care read Atul Gawande's collection of anecdotes about other communities.