Effective and consistent transitions of care are crucial to preventing unnecessary admissions and readmissions to the hospital. Our care management program developed a pathway for seamless transitions of care between ambulatory, emergency department, acute hospital, post-acute, and an integrated payor care teams to provide extraordinary care. Our integrated approach and processes allow us to continue to perform at a high level in quality outcomes and transitions of care. Simplifying our processes has been the key to sustaining high performance in this space and is the result of years of concerted effort.