1. Provide greater continuity of care between health care
facilities and the patient’s home
2. Offer post-discharge follow-up visits to help patients
transition to their homes, maintain their care plan, and avoid hospital
readmission
3. Refer patients, when appropriate, to urgent care or primary
care facilities
4. Help patients better navigate the health care system,
especially those with chronic comorbidities or complicated medical conditions
Source: Medlert, December 1, 2014
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