Care Coordination of Complex/Chronic conditions: Manages and coordinates care for patients with chronic conditions, complex medical needs, and assists with Discharge Planning: Helps plan and coordinate the discharge process for members leaving hospitals or long-term care facilities, ensuring a smooth transition to home or another care setting. Care Coordination - Transitions of Care: Outreach to patients that qualify for Transitions of Care (IP Discharge) and ensure they understand their medications, educate patients on managing their conditions and knowing when to seek help, stressing the importance of scheduling and attending follow up appointments, and teaching them to recognize the signs that their condition might be worsening.