“Patients discharged home and deemed to be at high risk for readmission were assigned a nurse Transition Guide (TG for 30 days post-discharge. All other patients were assigned the Patient Access Line (PAL) intervention, which provided a post-discharge phone call from a registered nurse. PAL and TG care coordination interventions were associated with lower rates of 30-day readmission. Our findings underscore the importance of determining the appropriate intervention for the hardest to reach patients, who are also at the highest risk of being readmitted. (J Gen Intern Med, Nov) Click here to read full text.