This episode features Liz Warman and Mandy Johnson from the Kansas Health Care Collaborative and focuses on the organization’s transition-in-care program that aims to leverage Health Information Exchange (HIE) to reduce care fragmentation and improve health outcomes by developing processes, workflows, and policies in clinics. This initiative is supported by grant funding from the Copic Medical Foundation and the model used has shown significant efficacy in reducing readmissions. The program received a high level of engagement from clinics and hospitals across Kansas and next steps include creating a rural network of facilities using HIE data, with the goal of scaling the model nationally to improve rural healthcare quality and reduce costs.