DescriptionSummary:Facilitates Care Transitions Intervention to include interdisciplinary collaboration across transitions and coaching the patient and caregiver to play a central active role in the formation and execution of the plan of care. Facilitates the intervention by identifying and meeting with patients in the hospital, performing home visits and follow-up phone calls. Introduces patient to self-management tools with the following goals: Medication self-management; Use of a dynamic patient-centered record; Primary Care and Specialist Follow-Up; Knowledge of Red FlagsCHRISTUS Spohn Hospital Corpus Christi-Shoreline overlooking Corpus Christi Bay is the largest and foremost acute care medical facility in the region, with a full ran
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