The need for population health tools which span the transitions of care are great. mHealth and remote monitoring solutions provide a platform to increase engagement across communities. This AHRQ snapshot points to evidence that using mHealth as a platform reduces readmission's, lowers cost, and leverages tablets and nurse coordinators to accomplish this feat. The study was conducted in Northeastern Massachussets at Elder Services of Merrimack Valley. Merrimack particpates in the Community-based Care Transition Program (CCTP).