The Michigan Transitions of Care Collaborative, or M-TC2, is part of the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program (PGIP) (see www.valuepartnerships.com). The BCBSM PGIP supports and facilitates practice transformation by rewarding Physician Organizations (POs) for improved performance in health care delivery. The goal of M-TC2 is to improve care transitions between inpatient and outpatient settings. The primary focus is the transition from hospital to home. The Society of Hospital Medicine (SHM) Project BOOST (Better Outcomes for Older adults through Safe Transitions) is being used by the collaborative. Project BOOST provides resources to optimize the hospital discharge process. The objectives of the initiative include promoting collaboration among POs, hospitals, & hospitalists as well as promoting safety by increasing discharge communication. The long term goal of M-TC2 is to decrease the occurrence of potentially avoidable re-hospitalizations within 30 days.