Primary outcome We will use the t-test for proportions to examine the difference in the proportions of patients in the educational and usual care groups who are re-hospitalized or die within 90 days of discharge. In addition, we will employ logistic regression to examine whether the educational and usual care groups differ on re-hospitalization/death (yes/no) at 90 days adjusted for pertinent covariates. We will conduct a secondary analysis to test the robustness of these findings. That analysis will examine whether time to re-hospitalization/death differs between the educational and usual care groups using the log rank test and the proportional hazard (Cox) model.