SERVICES
Care Coordination
Outreach
Telephone Reassurance
Health Risk Screens
Annual Care Planning
Monitoring
Home Safety Checks
Skilled Nursing Facility Deflection/Diversion
Transitional Care
Evidence-based Bridge Model of Transitional Care starting at hospital or SNF bedside
30-day and 90-day options
Home visits within 24-48 hours of discharge with a home safety risk assessment
specialized programs
Workshops & trainings