The transition care coach utilizes professional clinical judgment and critical thinking skills to assess patient and family scenarios for clinical appropriateness for the setting and establishing plans for effective management of their applicable disease process within the continuum of care. Assessment, planning, intervention and reassessment are performed in a collaborative environment in both the hospital and home setting. The key goals of the care transitions coach include proactive, individualized planning for patients' progress that optimizes quality of care, appropriate utilization and patient satisfaction.