Community Transitions

Helping clients get home and stay home from hospital and long-term care stays. Especially ideal for complex cases where limited or no family is involved or the family lives at a distance.


Collaborate with hospital care manager to ensure discharge plan is properly carried out

Assist senior orphans

Coordinate care needs with long-distance family

Facilitate communication between family, client, and healthcare providers to ensure appropriate quality care

Follow-up post-discharge, including medication compliance, DME, and home health (OT, PT, ST)

Continued patient education at home – medication, precautions, equipment, and more

Coordinate other services (including non-medical) to lower client costs

Implement weekly program to ensure client compliance and prevent re-admissions (see Wellness Program)

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