title: Profile of a continuing care program emphasizing discharge planning.
mesh_terms: D000359:Aftercare; D003153:Community Health Services; D003256:Community Participation; D003191:Comprehensive Health Care; D003266:Continuity of Patient Care; D006760:Hospitalization; D008499:Medical Records; D010347:Patient Care Planning; D010348:Patient Care Team; D011637:Public Health Nursing; D012017:Referral and Consultation; D012947:Social Work