Continuity of care between hospital and home.
D000046:Academic Medical Centers; D000368:Aged; D003152:Community Health Nursing; D003266:Continuity of Patient Care; D003704:Dementia / Q000451:nursing; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008297:Male; D009518:New York; D009720:Nurse Clinicians; D010351:Patient Discharge; D011320:Primary Health Care