- 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
