Safe Discharge.
Not Just a Signed Form.
Hospital discharges happen fast. Plans are handed to families with 15 minutes of explanation. Nurse Navigators intercepts this moment — reviewing the plan, asking the clinical questions families don't know to ask, and managing everything that comes after the discharge.
If your family member is being discharged in the next 24—72 hours: Call us directly at (520) 201-4033. We can engage same-day for urgent discharge situations. Do not wait to submit a form — call.
Three-Phase Bridge Protocol
Our Hospital-to-Home Bridge spans three distinct phases — from the moment of discharge through 30 days post-transition.
Discharge Review & Advocacy
- Review the discharge plan with you and the care team
- Ask the clinical questions families don't know to ask
- Confirm next-step placement is appropriate and safe
- Collect and organize all discharge documentation
- Clarify medication changes and follow-up requirements
Care Setup & Coordination
- Coordinate home health, DME, and specialist follow-up
- Communicate changes to the primary care physician
- Ensure medications are filled and instructions understood
- Set up in-home support services if needed
- Care documentation and coordination begins
30-Day Stability Check
- Scheduled check-ins to assess stability and catch early warnings
- Accompany to follow-up appointments if requested
- Coordinate specialty referrals if new needs emerge
- Readmission risk assessment and prevention support
- Transition to ongoing NNP Care if appropriate
In the Room, On Your Side
Read every line of the discharge paperwork — not just the instructions page. We flag missing orders, unclear medication directions, and incomplete follow-up requirements before you leave.
Evaluate the discharge destination — Is this SNF actually appropriate for your mother's acuity level? Is home safe without 24-hour support? We give you an honest assessment, not a form answer.
Communicate changes to the PCP — Hospital teams hand off to the primary care physician in writing. We make sure the PCP actually knows what changed — because they often don't get the full picture.
Coordinate the next 30 days of care — DME orders, home health start dates, specialist appointments, physical therapy, medication management. We own the coordination so your family can focus on being a family.
Hospital-to-Home Pricing
Hospital-to-Home Bridge is quoted based on the complexity of the discharge situation, duration of engagement, and level of ongoing support needed. Contact us for a same-day quote.
Pricing Approach
RN Navigator consultation: $450 flat for initial discharge review and plan.
Ongoing coordination is billed at our standard care rates.
Full 30-day Bridge programs are quoted individually based on scope.
Private-pay only — no insurance or Medicare billing.
Hospital-to-Home FAQs
Can you engage while the patient is still in the hospital?
+Yes — and this is the best time to engage. We can work with hospital discharge planners, review the inpatient care plan, and be present at discharge planning meetings. The earlier we're involved, the more effective the transition.
What if the discharge happens faster than expected?
+Call us immediately at (520) 201-4033. We handle same-day urgent discharge situations — we won't ask you to wait for a form response when your family member is being discharged in hours.
Do you work with the hospital discharge planner?
+Yes. We communicate directly with the hospital's discharge planning team, social worker, and case manager — working as an advocate for your family within the system, not in opposition to it. Hospital staff generally appreciate having a clinical advocate who understands their language and constraints.
Is a Discharge Happening Soon?
Don't wait until you're in the parking lot holding a stack of discharge papers you don't understand. Call us before discharge day — even 24 hours of lead time makes a significant difference.