Refer patients at discharge who are high-risk for readmission or struggling with chronic conditions. We provide in-home medical visits, telehealth follow-ups, medication reconciliation, and social support within 24–48 hours of discharge.
Connect patients facing barriers such as food insecurity, unstable housing, lack of follow-up care, or mental health needs. Our team provides in-home support, health screenings, and warm handoffs to local resources.
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