Qualifications/Responsibilities: The CTM is a Registered Professional Nurse who assesses, plans, intervenes and evaluates the patientís transitional care experience from the inpatient hospital setting to the home environment. The CTM focuses on the 4 key pillars of the care transitions process based on current evidenced based literature. These include but are not limited to information transfer in the patient centered record, medication management and teaching, timely follow up with primary or specialty care providers, and red flag disease exacerbation indicators that may result in an inpatient readmission. He/she empowers the patient/care giver to take on an active role during care transitions and to develop self care management skills. The CTM supports patients eligible for the program over a sixty-day period that includes hospital visits, follow up phone calls, co-management with designated medical management programs and/or home care visit if indicated. The CTM is an integral member of the Care Management Team and communicates appropriately serving in the capacity of consultant and educator, particularly with respect to promoting principles of case, complex and disease management, facilitating efficient patient navigation in the transitional process, troubleshooting and/or escalating issues. He/she submits timely and accurate reports based on transitional care interventions. Additionally, the CTM participates in performance improvement (PI) and research projects designed to address care transitions management across the continuum.