Transitions is a 30-day post hospital program that consists of weekly coordination as follows: 2 visit and 3 phone call: Initial phone call – to set up appointment and instruct them to have their Medications available and discharge paperwork from hospital. 1st visit is to identify and review the red flags that resulted from the hospitalization and educate how to manage the signs and symptoms. Complete a Medication Reconciliation and Member Survey. 2nd phone call – is to ensure that they have made their follow up PCP appointment and to schedule 2nd visit. 2nd visit is to review that they have managed the signs and symptoms, consulted with their PCP, and are compliant to any changes made by the PCP. 3rd phone call is to DC from the Transition program with a determination of professional view that the Member is now managing independently or criteria has been met for the move to Long Term program.