Inclusion Criteria:  - Participants will be recruited from those identified by a developed electronic health record list of patients with stage III AKI (severe) during a hospitalization based on serum creatinine rise or urine output decline from Olmsted County.  Exclusion Criteria:  Dementia. Non-English speaking. Expected to be dismissed to a skilled nursing facility or hospice at discharge. Expected to need dialysis at discharge. Primary Care Transitions Program enrollment. Transplant recipients within 100 days of transplant. Can only have one time enrollment.