Vendor needs to provide hospital, nursing home outreach and education service. • Participate in pilot initiatives, rapid–cycle testing, and evaluation activities as directed by the Department, to identify replicable models for statewide implementation • Maintain structured coordination with Aging and Disability Resource Centers (ADRCs) through monthly case review meetings, shared protocols, and regular cross–training • Use person–centered approaches to help strengthen transition outcomes • Gather data, at the direction of the Department, to support the State’s Division of Long–Term Supports and Services (DLTSS) post demonstration sustainability plan • Conduct outreach and educational activities for all hospitals and nursing homes within the covered region to promote