A large non-profit healthcare system with hospitals throughout Tennessee was required to reduce unnecessary readmissions, improve care coordination and enhance patient engagement and experience to improve its performance under the Hospital Readmissions Reduction Program (HRRP). Hospital readmissions contribute to a significant proportion of healthcare costs. Medicare reports that 2M patients are readmitted each year at a cost of $26B and estimates $17B of that comes from potentially avoidable readmissions. Research demonstrates that minority and other vulnerable populations are more likely to be readmitted for chronic conditions within 30 days of discharge. Findings showed that while not all readmissions are avoidable, a portion of unplanned readmissions may be prevented by addressing the barriers patients face before, during, and after admission and discharge.