This article details Community Care of North Carolina’s transitional care initiative for high-risk, Medicaid and Medicare patients. The program includes home visits, the use of motivational interviewing, patient self-management notebooks, care coordination throughout the hospital stay and beyond discharge, the inclusion of pharmacists, behavioral health providers and palliative care specialists in the care team as well as several other key components. Over a six-year period, Community Care reported a 10 percent drop in hospitalization rates for the population of interest. Full details of this promising practice can be found at https://www.communitycarenc.org/population-management/transitional-support/.