When a patient is readmitted to the hospital within 30 days of discharge because they failed to receive adequate care, it's known as an avoidable readmission. And unfortunately it happens more frequently than it should, particularly among medically underserved populations like the elderly and those who live in rural areas. "Many of these patients are eligible for transition services, but if the referral is not made prior to discharge, they don't even know to ask about them," says Maria Steele, a clinical assistant professor in the College of Nursing at The University of Alabama in Huntsville (UAH). "Then they fall through the cracks and have to manage on their own, and it's not the optimal outcome." So to combat the trend, the Centers for Medicare &amp; Medicaid Services (CMS) recently launched a new initiative under the Affordable Care Act called the Community-based Care Transitions Program (CCTP). Its goal is to facilitate the coordination of community partners to improve the care patients receive as they transition from the hospital to their homes.