In 2018, Door County Medical Center (DCMC) implemented Transitions of Care Management (TCM) for Medicare patients only. Through the COVID pandemic, readmission rates increased significantly and were occurring for many non-Medicare patients within 30-days of discharge. In July 2021, DCMC implemented an expanded TCM program to cover all adults regardless of payor source. In addition to one phone contact and follow-up visit post-discharge, an in-hospital visit was added. This service was also provided for the full 30-days post-discharge. The patient experience, elements of TCM, preventive practices, and diagnosis-specific support were the methods implemented. As a result, all cause readmissions decreased from 5.4% to 3.9% over a period of 12 months. As of March 2023, all cause readmission rate has reduced to 3.1%.