The Transitional Manager (TM) is responsible for proactively coordinating care and assisting with transitioning medically complex patients from the hospital to home. The TM works collaboratively with physicians and nurses in the hospital, primary care providers, care managers in the ambulatory setting and community, home care, and other members of the multidisciplinary care team in order to ensure the transitional needs of patients/families are identified and met. The TM will assess patients to identify risks impeding adherence to medical treatment plans, coordinate with the hospital care teams during the patient's stay, and assist patients and caregivers with the identification of issues/goals/interventions. They will follow-up with patients and caregivers for 30 days post discharge in order to ensure safe transitions of care and help reduce unnecessary hospital readmissions and ER visits. The assessment will take into account the patient and his/her caregiver’s perception of needs in order to make a safe transition from hospital to home.