Discharge & Post-Hospital Follow-Up

Within 24 hours of hospital discharge, we contact clients to review their discharge instructions, confirm that medications have been filled, and ensure follow-up appointments and home health services are in place. This proactive approach helps prevent complications, confusion, and unnecessary readmissions, giving clients the best chance for a smooth recovery.

Emergency Room Utilization & Support

For clients who frequently visit the ER, we identify the underlying causes and provide targeted education and care coordination. By teaching symptom management, arranging community services, and ensuring consistent follow-up, we help reduce avoidable ER visits and promote stable, ongoing care.

Social Determinants of Health Assessment

Health is shaped by more than medicine. We assess factors such as housing, transportation, food security, childcare, and financial stability to uncover barriers affecting each client’s well-being. Our care manager connects clients with local and state resources to bridge these gaps—ensuring access to the essentials of daily living that support overall health.

Care Coordination & Advocacy

We act as a bridge between clients, healthcare providers, and community resources. From preparing lists of questions for doctor visits to interpreting complex medical instructions, we help clients feel supported, understood, and empowered. Our nurse advocate ensures every client’s voice is heard and their care plan reflects their unique goals and circumstances.This is a sample text