We provide in-home medical assistance for patients transitioning between different levels of care. This includes hospital to home, supported care to home, and home to supported care. We coordinate with primary care physicians, specialty physicians, allied health providers, and home health agencies.

We specialize in:

• Coordination of discharge planning
• Complex and chronic illness management at home
• Post-discharge physician visits
• Medication reconciliation and pharmacologic assessments
• Caregiver and family support
• Community resource and referral services
• In-home medical monitoring
• Medical information management, and
• Assistance in planning for future health care needs

We are a liaison between home-based and non-home based medical services and can help prevent hospital readmissions through our involvement with coordinated discharge planning.