Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in medication(self)-management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, and knowledge of red flags. Interacts with physicians, and other providers, patients and families to coordinate services for patients’ post-hospital care in a timely manner and follow-up to ensure appropriate care is received.