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.