Discharging patients from the hospital is a complex process that is fraught with challenges. There were over 35 million hospital discharges in the United States in 2010 . Among Medicare patients, almost 20 percent who are discharged from a hospital are readmitted within 30 days . Unplanned readmissions, at a cost of USD $17.4 billion, accounted for 17 percent of total hospital payments from Medicare in 2004 [2,3]. Preventing avoidable readmissions has the potential to profoundly improve both the quality-of-life for patients and the financial well-being of healthcare systems.