Key Words: Discharge Planning, Home Health, MCG Guidelines, Social Services, Health Care Navigator, Discharge Planner, Care Manager, Case Manager, LVN, LPN, Licensed Vocational Nurse, Licensed Practical Nurse, Continuity of Care, Transition of Care / Transitional Care, Interdisciplinary Collaboration / Multidisciplinary Team, Comprehensive Patient Assessment, Acuity & Functional Assessment, Medication Reconciliation, Patient & Caregiver Education, Post-Acute & Resource Coordination, Durable Medical Equipment (DME), Home Health Care / Home Care Services, Skilled Nursing Facility (SNF) Placement, Inpatient Rehabilitation / Long-Term Acute Care (LTAC), Community Resource Linkage / Utilization, Transportation & Follow-up Scheduling, Compliance, Payors & Quality Metrics, Medicare / Medicaid Guidelines, Condition of Participation (CoP), Readmission Prevention / Reducing 30-Day Readmissions, Utilization Review (UR) / Case Management, Insurance Verification & Payor Source Management, HIPAA Compliance & Confidentiality. 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.