RN-led transition plan
An Embrace RN assesses needs, risks, routines, and practical barriers in the home.
RN-led support for referral partners
A stronger handoff home, backed by RN-led coordination.
We work alongside hospitals, facilities, physicians, and care managers to address the practical barriers that can derail recovery and contribute to avoidable readmissions.
Why refer to Embrace
Working with you to reduce avoidable readmissions.
A sound clinical plan can still break down when a person gets home without transportation, meals, hands-on support, clear follow-up, or a family member who can coordinate everything. Our RN-led services are built to reinforce the transition plan and help close those gaps.
Time-sensitive support
Transition packages address the critical first 3–14 days after discharge.
One connected pathway
Clients can move from short-term transition help into Care Navigation or recurring Personal Care.
Coordinated follow-through
With authorization, we confirm service fit, timing, and next steps and help keep the family and referral source informed.
From discharge plan to daily life
Clinical instructions are only useful if the home situation can support them.
Embrace complements clinical care by helping patients and families manage the nonmedical realities that influence whether a transition succeeds.
Identify barriers early
Assess the home, routines, support system, transportation, meals, mobility, and caregiver capacity.
Put support in place
Coordinate personal care, meals, transportation, reminders, home setup, and family communication.
Keep the plan connected
Use Care Navigation or ongoing Personal Care to reinforce follow-through and surface changing needs.
Referral workflow
Simple for the referral source. Clear for the family.
- 1
Send the referral
Use the secure online form for patient or client information.
- 2
We review fit and timing
Our team evaluates location, service need, urgency, and current availability.
- 3
An RN leads the assessment
We contact the patient or family, explain options, and arrange the home assessment and evaluation.
- 4
Care begins with a clear plan
Services start after expectations, pricing, scheduling, and authorizations are confirmed.
Who we work with
Built to complement clinical and community care—not duplicate it.
We partner with the people responsible for a safe transition and bring RN-led coordination to the practical work that begins once the patient is home.
- Hospitals and emergency departments
- Inpatient rehabilitation facilities
- Skilled nursing and nursing facilities
- Physician and specialist practices
- Care managers, social workers, and discharge planners
- Senior living communities and community partners
Ready to refer?
Use the secure referral form for patient information.
For general referral questions, use our online contact form or write to referrals@embraceathome.com. Do not send protected or sensitive health information through standard email or the general contact form.