Medicare spending is expected to increase by 79% between the years 2010 and 2020, caused, in-part, by hospital readmissions within 30 days of discharge. This study identified factors contributing to hospital readmissions in a midwest heath service area (HSA), using Coleman's Transition Care Model as the theoretical framework. The researchers analyzed data from the Centers for Medicaid and Medicare Services and findings from a survey of seniors and a focus group of health professionals. The targeted HSA had a lower overall readmission rate than the national average, yet higher for surgical discharges in particular. Analysis of survey and focus data showed that factors centered around the area of patient-provider and provider-provider communication processes, patient adherence, and health literacy. The study's convenience sample limits its generalizability. However, findings are consistent with the theoretical framework and past research, demonstrating that the solution to the rising health care costs may be less high tech or pharmaceutical interventions per se but more fundamental communication among providers as well as with patients and caregivers.