This module examines issues related to health and social care among community dwelling individuals, living with multiple chronic conditions and who transit from acute to community care settings. Students will be introduced to concepts of health goals, care coordination and continuity of care throughout the episodes of illness. They will learn to streamline care plans to prevent re-admission and to prepare clients, their families and/or caregivers to implement their care plans in collaboration with multidisciplinary care teams and community partners. This module will equip students with the necessary knowledge and skills that would enable them to perform non-clinical roles such as care coordinators in the healthcare industry.