The aim of this paper is to outline improvements in the transition of care from the hospital setting to the community setting and to suggest initiatives to improve the level of support aiding in the successful transition of care. Improvements in medical care have helped increase the life expectancy of Americans. It is expected by 2030, 20 percent of the American population will be 65 or older, meaning close to 71 million people. This suggests that more Americans are and will be dealing with added chronic conditions. Research has indicated that collaboration along the continuum of care is essential for a successful transition of care from the acute hospital setting back to the patients' previous setting. This paper focused on the formation of a hospital-based home health agency to care for the patients being discharged from one critical access hospital back to their previous setting of home as an intervention for a successful transition.