In partnership with Jewish Family & Children’s Service of Greater Mercer County, Robert Wood Johnson University Hospital-Hamilton is using the Care Transitions Intervention model to improve care transitions for 350 Mercer County residents from Hightstown, Trenton, Hamilton, Mercerville, Yardville, Ewing, Lawrenceville and Washington Township hospitalized with congestive heart failure and/or diabetes, at least one other chronic condition, and one or more social vulnerabilities (primarily advanced age, low income, and/or disability). Expected outcomes include improved patient engagement in the management of their health care, reduced re-hospitalization rates, lowered costs to patient, hospital, and insurance companies, and improved quality of care.