• Assist patients with healthcare needs following discharge from Hospitals or Skilled nursing homes or Rehabilitation centers to home.
  • Discharge instructions follow through.
  • Care provided by interdisciplinary care team (Skilled nursing, therapies, Medical social worker, Home health aides) as appropriate.
  • Assess home safety
  • Assess and manage potential accommodation
  • Reconcile medications and communicate to primary care provider.
  • Identify and offer community resources
  • Ongoing patient and family education and training
  • Assist with physician appointments and resource for transportation