The Transitions of Care (ToC) program was implemented to strengthen continuity of care between NewYork-Presbyterian inpatient units and subsequent settings to reduce the risk of avoidable 30-day readmissions to the hospital and/or emergency department. The ToC model is currently operating at the NYP Allen Hospital, Milstein Hospital at NYP/Columbia Irving Medical Center, NYP/Weill Cornell, and NYP Lower Manhattan Hospital. The program aims to identify and engage Medicaid patients at increased risk for readmission to provide education on disease and self-management, facilitate timely follow-up with primary care provider(s), and coordinate medical and social service needs to overcome barriers to safe transitions. The ToC program partners with the Center for Community Health Navigation Community Health Worker (CHW) program to reinforce education in a linguistically and culturally appropriate manner, and to provide home visits and accompaniment to follow-up appointments. More than 1,100 patient discharges were reached in 2017.