The Care Transition Coach coordinates care across an episode of illness of the patient with multiple chronic conditions. Utilizes the nursing process to develop individualized plans of care for safe and effective movement of patient across the care continuum, serving as the bridge between the professional staff in a care setting and the patient and/or family. In this role, as a patient educator-advocate, and patient empowerment facilitator, the Transition Coach utilizes education and community services to develop patient/family/caregiver problem solving and self management skills. Fosters communication, builds collaborative relationships and enables patient/family/caregiver to better navigate the health care system. Focuses knowledge deficits and behaviors that interfere with recovery, cause harm or re-hospitalization.