In this pilot project, we examined processes at the patient and organizational levels to identify factors that facilitate or impede seamless care during this critical period of transition. Our objective was to identify ways to maximize improvement in postdischarge patient outcomes. This pilot research project targeted patients at risk for unscheduled readmissions within 30 days of their original hospital discharge. Additionally, it examined patient and organizational factors contributing to such discharges, and sought to identify possible interventions for providing a more seamless transition of care.