Underwood-Memorial Hospital will assemble and integrate several of the best practices in the country in the area of medication access, adherence to prescribed therapy and patient education, and is designed to improve patient outcomes by preventing avoidable hospital readmissions and post-discharge adverse events, and reducing duplication of services and resources.  The target population is patients from Gloucester, Camden and Salem Counties age 65 and over with multiple chronic conditions who are readmitted within 30 days and/or have been admitted to UMH six times or greater in the past 12 months.