Utilizing an Advanced Practice Nurse in a shared position among eight community providers, the collaborative strives to break down the barriers to care and ability for patients to self manage their chronic illnesses and health needs.  Interventions include APN contact upon admission, throughout hospital stay and before and after any transition among providers, customized educational workbooks, enhancement of practitioners skills in caring for chronically ill patients and in understanding the transition process, enhanced communication between the APN, the treating and community physician, universal tools such as risk assessments, transfer summaries, medication reconciliation, readiness to learn, transition surveys and patient centered careplans.