In 2020, nearly half the nation’s hospitals were penalized by CMS for high readmission rates. However, research suggests as many as 75% of readmissions could be prevented or reduced in severity with the right interventions, coordination and communication that meets patient needs. But to do so, care teams need to know which patients are at risk of readmission and how their risk can be reduced. Clinical AI can provide the answers to these difficult questions. To reduce readmissions and lower costs, one of the largest healthcare providers in New York State decided to augment their transitions of care management (TCM) program with the prescriptive clinical intelligence of the Jvion CORE™.