For patients that are unable to come to the office—in hospital, SNF, LTC or homebound, engages with the transitional care team and others including case managers, acute and transitional-care physicians, and other resources that may be available depending on the market. Leads Super Huddle (SH) and Transforming Care Meeting (TCM) weekly, as well as supports Center Manager/Center General Manager center clinical leader and/or market clinical leader is not available, based on guidance from Market Chief Medical Officer.