RN-led home review
Review the discharge, current needs, risks, routines, personal-care needs, and practical barriers.
RN-led support for referral partners
The handoff should not end at the car.
We work alongside hospitals, facilities, physicians, and care managers to carry the plan into the home, address practical barriers, and help reduce avoidable readmissions.
The gap after discharge
A clinically sound plan can still fail in an unsupported home.
The patient may be escorted to the car with instructions but still arrive home without medications, usable equipment, safe mobility support, meals, transportation, caregiver capacity, or one person tracking the follow-up. Those are the gaps Embrace is built to address.
First-week support
Embrace Homecoming combines one RN home visit, three caregiver visits, and seven days of coordination.
Ongoing coordination
A primary RN can remain involved through two scheduled visits each month and coordinated follow-through.
Hands-on Personal Care
Caregivers help with mobility, personal needs, meals, routines, reminders, errands, companionship, and respite.
Working with you to reduce avoidable readmissions
Close the practical gaps that can send someone back.
Embrace complements clinical care by helping patients and families manage the nonmedical realities that influence whether a transition works at home.
Identify barriers early
Surface medication access, equipment, mobility, meals, transportation, follow-up, home safety, and caregiver-capacity concerns.
Support the plan at home
Use RN-led review, caregiver instruction, reminders, practical assistance, and appropriate escalation when concerns are reported.
Coordinate follow-through
With authorization, help connect providers, therapy, pharmacy, equipment, appointments, the client, and family.
Referral workflow
Simple for the referral source. Clear for the family.
Send the referral as early as possible. Timing and service fit remain subject to assessment and availability.
- 1
Send securely
Use the secure referral form for patient or client information.
- 2
We review fit and timing
Our team assesses needs, discharge timing, location, requested support, and availability.
- 3
We speak with the client or decision-maker
We explain scope, expectations, scheduling, payment, and the written service agreement.
- 4
We coordinate the start
When accepted, we organize the RN visit, caregiver support, communication permissions, and next steps.
Who we work with
A flexible private-pay resource for the plan beyond discharge.
Refer for Embrace Homecoming, ongoing RN-led Care Coordination, Personal Care, or a connected plan based on assessed need.
- 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
Secure referral
Ready to connect a client with Embrace?
Use our secure referral portal for sensitive patient or client information. For nonclinical questions, contact referrals@embraceathome.com or call 405-735-7166.
Embrace provides private-pay, nonmedical home-care services. Acceptance is subject to assessment, service-area fit, staffing, availability, written agreement, payment arrangements, and any required provider order. Outcomes, including readmission avoidance, are not guaranteed.