Maxlink Health RN Care Coordinator converts discharge orders to care transition plans, ensures medication reconciliation and performs care coordination alongwith patient education and scheduling of PCP follow up. This program relies on Registered Nurses at Care Team 365 who enrolls the Patient into the program and begins their care cycle. The RN begins successful transition from Hospital to home including medication review and preparing patient to begin self-management at home. RN educates patients about their condition and warning signs and communicates with family caregivers. Patients can engage in real time communication with the RN.