In your home we are charged with recognizing symptoms of distress through regular medical monitoring. The RN will regularly take your vital signs, and monitor all of the concerns specific to your health care needs. It can be impossible for you to go to your PCP or Specialist in this crucial time of transition. We come to you. The home health care team includes the RN, PT, OT, ST, MSW, CNA and medical oversight by MD and Nurse Practitioner. During the weeks following your hospitalization while you are basically home bound, you can count on frequent visits and 24/7 phone support. Occasionally visits by the Transitions Chronic Care team may be needed, and are available to the Transitions Home Health Care patients. Together they provide the optimal coverage in complex condition management.