The purpose of this paper is to discuss the importance of effective discharge planning process, with the goal of reducing readmission rate and frequent emergency room visits. This paper will analyze the new transitional care model recently introduced to improve organization discharge planning process. The hospital discharge planning is a complex process that requires extensive communication between the sending facility and the receiving institution, in efforts to reduce readmissions. An interdisciplinary team of six stakeholders formed an investigation committee to find solutions to high readmission rate, unnecessary healthcare expenses, frequent hospital visits. The team used the newly developed Transitional Care Model(TCM) methodology
