To improve care transitions for complex, costly, and high utilizing patients, with a goal of reducing unnecessary hospital readmissions in the City of Camden, trained nurse care coordinators and health coaches will be embedded in local Federally Qualified Health Centers. The care transitions team will also work with hospital-based social workers, hospitalists and discharge planners to coordinate the planning and post-discharge continuity of care. Emphasis will be placed on inter-professional case-conferencing among hospital and clinic care providers.  Project outcomes will ideally reflect a reduction in hospital readmissions, reductions in hospital costs and increased primary care coordination in Camden.