When MMR Healthcare started using Transition Care Management from eClinicalWorks, they learned the chronic heart failure, falls, and influenza were the leading causes for hospital readmissions among their patients. With unified dashboards to keep all providers informed about each case, they have improved compliance with follow-up appointments, helped patients with their medications, improved patient education around diet and lifestyles, and reduced their hospital readmission rate down to 10-12%, well below the national average of 18%.