A significant part of the Transitional Care NP role is to facilitate each patient’s and family caregiver’s ability to manage his/her care at home. The Nurse Practitioner begins this process at the point of hospital admission, working with each patient and family caregiver to identify their goals. Across the next one- to three-months, in the home, the Nurse Practitioner helps patients develop systems for effectively managing their own care and achieving their goals. The Nurse Practitioner works with the patient and family caregivers to develop an individualized, realistic plan of care that includes strategies to reach positive health outcomes aimed at preventing future acute care events. The primary goal is to help patients and families develop the knowledge needed to identify and address health problems when they first occur. Each plan is customized and tailored to the individual patient and identifies the resources and level of change that patients and their family caregivers are willing to accept and able to execute. At hospital admission and the first home visit, the Nurse Practitioner performs medication reconciliation to assure the correct medications, in the correct doses, are documented in the patient’s medical record and present in the home. Additionally, the NP assesses the patient’s current system for managing medication and obtaining refills, and suggests changes to medication behavior as needed (e.g., obtaining pill planners, 90 day supply ordering). In addition, the Nurse Practitioner identifies environmental risks, social needs and available supports, and arranges community services as needed.