transitioning Medicare eligible patients from the hospital to their home by providing intensive care management services through home visits and follow-up phone calls, medical appointment reminders, in-home medical services in the nature of assistance with scheduling medical appointments, medical counseling regarding one's medical diagnosis and medication reconciliation consultation with patients about prescription medication interactions and use

transitioning Medicare eligible patients from the hospital to their home by providing intensive care management services through home visits and follow-up phone calls, assistance with scheduling medical appointments, education on diagnosis, medication reconciliation, home safety checks and referral to home and community based services