Alameda County Medical Center (ACMC) has received a $690,926 grant from the Gordon and Betty Moore Foundation to launch a transitional care programme at its Highland Hospital in California.
The programme aims to reduce preventable readmission rates at the facility.
ACMC chief of medical staff Dr Lyn Berry commented: "The transition from hospital to home is a challenge for high risk patients who don't have adequate support after discharge."
"The Gordon and Betty Moore Foundation grant will enable us to place increased focus on the patients who need additional education, comprehensive assessment, and transition planning - all of which have been shown to reduce the incidence of preventable readmission," Berry added.
"The grant will be implemented by a multidisciplinary team that has successfully piloted this project for the past year."
Berry added that the transitional care programme aims to minimise Highland's 30-day all cause preventable readmission rate for high risk patients by at least 30%.
The programme also aims to reduce the 90-day all cause preventable readmission rate by at least 15% compared to 2010 baseline rates.
In the US, one-fifth of medicare patients are readmitted to the hospital within 30 days of discharge while 34% are readmitted within 90 days.
Highland Hospital, which is below the national average for unplanned readmissions, had an 11.4% readmission rate for patients within 30 days and a 19.3% rate within 90 days in 2010.
Unplanned hospital readmissions are estimated to cost the US more than $17bn every year.