Transitions of Care across the healthcare system are both common and treacherous for patients. Re-admission and unnecessary ED visit rates remain high in the US and are costly. Medicare introduced Transition of Care (TOC) codes in January of 2013. TOC visits provide the opportunity to reduce the risk of hospital re-admission and unnecessary emergency department visits, via coordination of care and in-person visits soon after discharge. By using Encounter Notification Systems (ENS) through a statewide health information exchange (HIE), our small practice team designed, implemented, and refined transition of care protocols over a 6 year period of time, with a net reduction in re-admission and ED visit rate. We use aggregated HIE data to assess our progress and to identify opportunities for change. We believe our protocols can be adapted to other settings and hope to inspire greater implementation of this vital service in primary care settings.