Uses Coleman Transition Intervention to help people after they are discharged from a health care facility. Following hospital discharge, patients often require care from different medical professionals in many different settings. This program is designed to improve the continuity of care for persons with chronic conditions across different health settings and ensure that each transfer between setting goes smoothly. This is a FREE service to assist people to recover, understand and manage your medications better, prevent hospital re-admissions, and plan for a follow-up appointment with your primary care physician.