“A patient-centered medical home provides patient-centered, comprehensive, and coordinated care that supports patient self care; offers superb access to care; and employs a systems-based approach to quality and safety (Taylor, Lake, Nysenbaum, Peterson, & Meyers, 2011).” After experiencing a medical emergency, the patient was initially hospitalized. Once stabilized to the point that she no longer needed hospitalization, she was transferred to a SNF for rehabilitation. Following rehab, arrangements were made amongst family members and a case manager to transition Heidi into a nursing home to assist with ADLs and IADLs because she was too severely disabled to return home. Upon significant improvement, Heidi was transitioned back home and had continued care with a home health agency providing physical therapy and a homemaker. All of these services were very well coordinated and supported Heidi’s transition to self care.…