The Delta Care Transitions program is a community-based project designed to improve health outcomes for at-risk, rural patients who transition from in-patient to out-patient settings. The goal is to reduce hospital readmissions, and thus cost, for patients with chronic illnesses who have a history of multiple hospitalizations. Developed in partnership with South Sunflower County Hospital and North Sunflower Medical Center, Sunflower Clinic, Indianola Family Medical Group and Leland Clinic, the program assigns specially trained patient navigators to ensure that individuals receive appropriate post-discharge follow-up care, patient education, assistance navigating health care programs, and access to support services for family caregivers. In this way, patients seek follow up care from local clinics and physicians, rather than from hospitals. Two objectives are realized: patients receive care that is typically more personal and more timely while reducing the overall cost to the health care system.