title: Hospital team reaches out to post-acute providers.
mesh_terms: D000046:Academic Medical Centers; D003266:Continuity of Patient Care; D006333:Heart Failure / Q000534:rehabilitation; D018574:Home Care Agencies; D006801:Humans; D019982:Organizational Case Studies; D010346:Patient Care Management; D012495:San Francisco; D012866:Skilled Nursing Facilities