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Transitional Care


When you are leaving the hospital to go home, we:

  • can pair you with an MSW and a Nurse case Manager to help manage your needs in the first thirty (30) days discharge from the hospital.

  • will work with the discharge planner at the hospital to make sure that all referrals are going to the appropriate home health agencies.
  • monitor you and your needs until you improve or offer you our next level of care - Palliative Care - in case you need a little more help after your thirty days are up.




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