Safely transitioning care

I am a [clinical role, e.g., hospital discharge planner, hospitalist, case manager] coordinating care for a [age]-year-old [gender] being discharged after [hospitalization or condition]. Outline the key information that must be communicated to: [receiving provider, e.g., primary care physician]; [home health or rehab service]; [specialist, if applicable]. Include active problems, medications, pending tests, functional status, and follow-up needs, formatted as a clear handoff summary.