In phase 1 of this planned five-year demonstration to reduce preventable rehospitalizations, the project team identified effective strategies for reducing avoidable rehospitalizations and developed resource toolkits for the three states selected to participate—Massachusetts, Michigan, and Washington. In phase 2, each state team will designate a leader to engage 10 to 20 hospitals in “learning communities” focused on improving care transitions and reducing avoidable rehospitalizations. Four policy committees of state and national leaders will address system-related barriers to reducing rehospitalizations—seeking to improve coordination across settings of care and develop statewide measurement strategies or public reporting policies. Other workgroups will be charged with developing recommendations for regulatory and payment reforms.