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Implement admission visits to develop individual plans of care.
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Review medication regimens, customizing them to best meet the patient’s needs.
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Provide medically necessary visits for routine care or emerging health issues.
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Consult with the nurses and other clinical team members to answer questions and review the progress of care.
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Provide progress reports, counseling of care, and outcome expectations to patients and their family members on a timely basis.
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Reduce avoidable transfers to the hospital and emergency room.
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Provide timely assessments and review of plans for transfer or discharge to home or a new appropriate care setting.