Purchase Area Health Connections (PAHC), a rural health Network in western Kentucky with an eight-county service area, received funding to: 1) to continue to strengthen the Network and its members; 2) to gain a better understanding of policies and trend in health care (such as value-based care) and explore their impact on rural health; and 3) to improve population health and reduce hospital readmissions with a system of transitional care that is augmented by technology that supports communications among the variety of electronic health record systems used in the region. PIRE is evaluating the efficacy of this program to reduce hospital readmissions.