Care coordination includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing interventions, managing the patient care transition process, assisting patients throughout care episodes, coordinating and facilitating care for patients with complex and chronic conditions, and promoting evidence based healthcare services. Conduct comprehensive assessments, identify problems/issues, establish goals, implement interventions, reassess needs, establish appropriate time-frame for frequency of follow-up activities, and provide closure and referral services, as appropriate and notify providers of readmissions and significant clinical status changes as appropriate.