especially ideal for complex cases where limited or when no family is involved or family is at a distance

Coordination and communication with physicians, insurers, families and specialists

Implementation of Collaborative Care Program (meeting with family; assessment of discharge needs; implementation of Care Plan; assistance from Care Manager and caregiver on day of discharge at facility and at home; medication pickup; transportation of client to home [if medically appropriate]; review of discharge instructions with Care Manager [with intervention if needed]; collection of needed physical therapy [PT], occupational therapy [OT] and/or speech therapy [ST] exercises; advocacy by Care Manager; medication setup in home; answers to clinical questions)

Home safety evaluation and arrangement of durable medical equipment (DME)

Referrals and coordination of all services (skilled home care, non-skilled home care, durable medical equipment, counseling, MD, rehab, dietitian, housing, legal, financial services)

Family consultation and mediation

Interview of caregiver companies with an overseeing of caregiver hiring with appropriate number of hours; education for caregiver (non-medical home care)

Advocacy at rehab/hospital and assistance to discharge (DC) home safely

Collaboration with discharge planner/community case manager, nurses, PT, OT, ST, MDs for care coordination

Documentation of health history/medication list for MDs

Provision of community resources and setup of Emergency Response System (e.g. Lifeline)

Provision of hands-on nursing care at home (e.g. wound care, gastrostomy tube feedings, head-to-toe assessment, notifications to MDs of significant findings to obtain orders)