This text discusses the Four Pillars of Care Transitions, which are Medication Management, Personal Health Record (PHR), Follow-up Care, and Health Coaching. It explains how these pillars are used in the Care Transitions program, which aims to improve the experience and health of older patients and their caregivers. The program also helps patients assert their goals and build confidence in managing their own health. This model is essential to ensure the continued well-being of elderly loved ones and to reduce readmissions to the hospital. To support care transitions, the Triple Aim framework is used, which focuses on improving the individual's experience of care and promoting population health. The model specifically addresses the needs of older adults and provides tools and resources to help them effectively manage their health. The Health Coach plays a vital role in guiding patients through these pillars and helping them achieve their goals, such as going back to church.