Coordination of care activities related to ensuring continuity of care between levels of care (e.g., inpatient to outpatient care) and across multiple services (e.g., personal care services, housing services, nursing services, and family counseling) and providers. Coordination of care with the patient, their Health Care Decision Maker (HCDM), healthcare providers, family of origin and/or choice, community resources, and other natural support systems and/or people including educational, social, judicial, community, and other State agencies.