Meet regularly with Health System Leaders and Value Based Care stakeholders that intersect with Post Acute Performance, such as Hospital leadership, case management, Value based care programs, Health Plan, Geriatric program, etc. to inform them of Home Health and Transitional Care Unit performance, and ensure the network continues to serve the health system and optimize outcomes for our patients. Lead a team of Transition of Care Managers and following patients in Transitional Care Unit and Post Acute Care programs to ensure proactive discharge planning and care management of patients, identify challenges with facilities or agencies, review specific care examples, and escalate concerns with facility performance as indicated.