Ms. Penick was working with a Veteran with complicated medical history. He has a history of stroke in the past that put him in rehab for 3 years and without a driver's license. When he returned home, he was more worried about getting his license back than anything else. With his cognitive impairment, his obsession with getting his license back, and his complicated health issues, multiple providers, and no support from family and friends, he was destined to be back in the hospital or worse. Since starting the remote patient monitoring home telehealth program, she worked vigorously to find someone to help with his driver's license issue. Finally, she connected him with the right path for this pursuit. She worked diligently on medication compliance. Recently, she noted that his BP and weight elevated dramatically. When she went to look at what medications the Veteran should be taking, she noticed multiple issues with multiple Providers either placing in their notes that he was taking a medication that was either not on his active list or multiple different doses. She contacted HF NN and NP, and they were able to get an updated medication list from the Jewish HF clinic and get medication list updated. She was able to call the Veteran and go over his medications, one by one, discovered missing medications that the Veteran had not refilled, called OP pharm for quick delivery, and has been in contact with the HF clinic as the Veteran is a patient with Cardio mems but no one is using it. It seems like due to his cognitive issues, they were not able to connect Cardio Mems, so it was basically just not utilized. VA HF Clinic stated that they will f/u on this situation. The Veteran's BP has stabilized, and he is on a path to see if he is eligible to get his driver's license reinstated. This exhibited a great catch in identifying missing components of the Veteran's care that were key to his successful recovery.