NC Notify+ is a product offering from NC HealthConnex that UNC Health leverages to conduct post discharge outreach, provide clinical support, and reduce risks of readmission for their AmeriHealth Caritas and WellCare patients. Once a roster of patients is uploaded to NC Notify+, if one of those patients is ever discharged from an NC HealthConnex participating hospital, a Direct Message containing the patients discharge summary is sent to Epic@UNC. This message is made available to the UNC Health Alliance Transitional Case Management (TCM) team through their EPIC In-basket. ADT alerts that include the name of the discharge facility, the patients’ diagnosis, and both admission and discharge dates, are reviewed daily by leadership and patients assigned to case managers for them to perform chart reviews using Care Everywhere and the discharge summary received from NC Notify+. The RN Case Manager performs outreach within two business days post discharge to identify gaps in care that would increase the risk of readmission. The outreach includes a transition assessment, medication review, and care planning for identified populations.