In collaboration with the Central Mass/MetroWest Transitions in Care Collaborative CMTCC), the Central Mass Health Literacy Project, designed and implemented a training program utilizing plain language to help reduce hospital readmissions. 21 transition care coaches were trained to look for red flags associated with 13 medical conditions responsible for high rates of hospital readmissions. Coaches met eligible Medicare patients in the hospital and followed them in the community for 30 days post discharge. The collaborative was funded by section 3026A of the Affordable Care Act. In 2012, we worked with Elder Services of Worcester, leading agency of CMTCC, to implement the training program. Readmission rates have decreased in the target population and CMTCC received additional 2 years of funding from CMS for their transition care program. Improving transitions from the hospital to other care settings, improving quality care to reduce readmissions for high risk patients and providing measurable savings to Medicare should be our community's goal.