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Inclusion Criteria and Exclusion Criteria: Patients were eligible if they were aged 21 years or older, being admitted to participating medical wards (general internal medicine, endocrinology, respiratory medicine, renal medicine, gastroenterology, neurology), at high risk of readmission (as determined by LACE score ≥ 10 [length of stay, acuity of the admission, charlson comorbidity score, and emergency department visits in the previous 6 months] score ≥10 [22] and at least ≥1 admission in the previous 90 days).
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