The Camden Coalition provides a care management program whose goal is to reduce unnecessary hospital utilization in Camden, New Jersey. The program provides care managers who intervene with high hospital utilizers to educate patients and empower them to take control of their health. The care managers work with patients to address any barriers that prevent them from following their care plans and connecting with a primary care provider. While overall the program shows much promise, in the early stages of the program, care managers were often waiting for referrals to be sent to them, and often received referrals for patients that did not meet the intervention criteria. The referrals were often made long after care was delivered to the patient limiting the potential impact of the program. In order to address these issues, the Camden HIE (an HIO supported by the Camden Coalition) developed a method for identifying high utilizers and notifying care coordinators prior to discharge from the hospital.