After completing the Fast Forward Rounds course, learners should possess greater knowledge of transitional care, improved attitudes toward promoting safe transitions and increased performance transitional care behaviors. Participants will report improved understanding of: - the roles of interdisciplinary team members (nursing, social work, physical/occupational therapy) - home care and community resources - the variety of care settings and housing options for older adults - the importance of performing a thorough functional assessment - Medicare and Medicaid reimbursement policies for various home, community, and housing services Participants will report increased proficiency in: - Performance of functional assessment - Communication with physician and non-physician providers (e.g., home health care workers, nurses, and other interdisciplinary team members) - Education of patients, families and caregivers - Medication reconciliation to prevent medication errors - Management of the discharge process of complex patients