Educates and supports member focusing on seven primary areas (Transition of Care Pillars): medication management, use of personal health record, follow-up care, signs and symptoms of worsening condition, nutrition, functional needs and or home and community-based services, and advance directives. • Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions.