The RN partners with patients, caregivers, hospital teams, primary care practices, pharmacists, home care, and community organizations to support a safe transition from hospital to home and reduce avoidable emergency department use and 30-day rehospitalizations. The RN coaches patients and caregivers to build the knowledge, confidence, and skills needed to manage medications, maintain an accurate patient-centered health record, complete timely follow-up, and recognize and respond to clinical red flags.