Who we help

The people we are usually called about

Most referrals reach us at a turning point — a discharge, a fall, a diagnosis, or a family caregiver who has run out of room.

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After a hospital or rehab stay

  • Hospital discharges
  • Skilled nursing and rehab discharges
  • Post-surgical recovery
  • Preventing a readmission

Memory and cognition

  • Alzheimer's disease
  • Vascular and Lewy body dementia
  • Wandering and exit-seeking
  • Sundowning and agitation

Chronic conditions

  • Heart failure and COPD
  • Diabetes
  • Parkinson’s disease
  • Stroke recovery
  • Arthritis and limited mobility
  • Cancer treatment

Safety at home

  • Recent falls
  • Unsteady walking
  • Living alone
  • Medications taken wrong or not at all

End of life

  • Hospice support at home
  • Comfort care
  • Family who want them home

The family

  • Caregiving spouses at the end of their strength
  • Adult children driving in every weekend
  • Families far away who need eyes on the situation
  • Veterans and their surviving spouses

Recognise someone?

Send a referral and a care coordinator calls you back the same business day.

Send a referral Apply to work with us