This 402 bed regional medical system has developed a comprehensive transition program to identify and guide patients from acute care through comprehensive discharge planning and into community care. In the process, hospital readmission reductions were attained using transition nurses to proactively manage patients with a high risk of readmission. Using the modified LACE (Length of stay, Acute admission, Co-morbidities and ER visits) tool to identify patients at risk for discharge delays and/or readmissions and analytics to evaluate target populations, the program has been successful. The analytics allow us to correlate the patient risk of readmission with the actual observed readmission rate, the total cost of readmission encounters, the clinical drivers of readmissions. They also provide a financial model that calculates the overall impact of readmission rate reductions on reimbursement, cost, and value based purchasing payments. The program includes 30 day any cause readmission and follows specific clinical populations of AMI, Heart Failure, Pneumonia, Hip/Knee Replacement, Stroke, COPD, and Sepsis.