Rush has developed a number of programs and processes to improve care transitions and coordinate with community providers. Their LTSS programs are integrated into interdisciplinary teams and community providers are engaged in the discharge planning process. Almost all of the participants in the transition process report an opportunity for improved communication and efficiency through technology. Some tools such as AllscriptsCare Management have been helpful in facilitating information exchange, but they are not consistently applied across all community providers and services. Coordination and deployment of services is at the heart of the LTSS programs at Rush. Staff spend a significant time with communication tasks (making calls, followup, sending faxes, verifying receipt) to share information with service providers. Technology and improved tools could be beneficial in supporting the work of LTSS providers.