Healthcare organizations are becoming more accountable for the patients’ health along with their illness. We have learned that even though we have provided great care and “checked all of the boxes” on the discharge checklist, patients leave our health care institutions confused and many times without the resources or support needed to keep them healthy. Care Managers not only need to understand the health plans benefit structure but also consider what happens to the patient when they leave they transition back to their home of community. Care Transition programs have opened our eyes to the reality beyond the brick and mortar buildings where patients lack transportation, fail to fill prescriptions, do not receive services that were ordered by their physician, such as durable medical equipment or physical therapy. MCB has worked with several healthcare organizations to recreate their case management services to ensure safe transitions to the next level of care and mitigate the gaps that contribute to readmissions or other poor outcomes and increase the cost of healthcare.