On January 17, 2012, SETMA’s Hospital Care Team and Department of Care Coordination met to discuss Care Transitions and Care Coordination.  In 2009, 2010, 2011, SETMA discharged 25, 995 patients from the hospital.  We changed the name of the discharge summary to “Hospital Care Summary and Post Hospital Plan of Care.”  We learned that two things significantly impacted readmission rates:  a care-coaching, post hospital follow-up call of 12-30 minutes and a follow-up clinic visit within in six day for all patients and three days for vulnerable patients.  In this meeting, as can be seen by the slide deck, we opening discussed our struggles with medication reconciliation and with effective continuity of care.  We recommended solutions and are in the process of implementing solutions.