This idea will attempt to address readmission to the hospital by identifying which patients are at high risk for readmission before they leave the hospital or before they are transferred from an ICU to a step down unit. The hypothesis for this idea is that if we are able to calculate a risk score for readmission and intervene early for those patients with a high risk score either before the patient leaves the hospital and after they are discharged from the hospital or ICU unit, the rate of readmission will go down with more targeted interventions. By assigning a risk score for a patient, it will help clinicians identify which patients are at higher risk for readmission for specific conditions. A transdisciplinary team can then put together a standardized bundle of prevention interventions for the patient for both pre-discharge and post-discharge based on their specific condition (example: no family support, poor drug adherence, hypertension…etc).