The Portland Veterans Affairs Medical Center provides a range of health care services for an aging population. The chronic, multiple health problems of veterans and the complexity of the health care delivery system often lead to fragmented and discontinuous care. The innovative model of advanced practice nursing described here involves using hospital-based community health CNSs in the role of community health coordinators. The three CNSs described here each have unique and overlapping responsibilities. Based primarily in the medical center, they are able to facilitate a smooth patient transition from the hospital to the community using knowledge and experience to assess, plan, implement, and evaluate care needs of three defined populations. In this article, responsibilities of the community health CNS are defined and the Portland VA Medical Center and population served are described. The history of the community health coordinator role is outlined, followed by the current role description and targeted populations, and role impacts to date.