Core deliverables include successful transitions of care, free standing emergency department care coordination, reduction of avoidable hospital utilization, improved patient engagement, reduced readmissions, closure of care gaps, population health outcomes, patient satisfaction, and connection to appropriate community resources. Collaborates with patients, families, physicians, advanced practice providers, free standing emergency department staff, ambulatory practices, post-acute providers, and community resources to coordinate care across the continuum and facilitate safe, efficient transitions between care settings and timely follow-up.