We provide care management by nurses and social workers for up to after a patient is discharged from a hospital or other facility where he 33 http://www.dartmouthatlas.org/downloads/reports/Our_Parents_Ourselves_021716.pdf http://www.chiamass.gov/assets/Uploads/A-Focus-on-Provider-Quality-Jan-2015.pdf http://www.chiamass.gov/assets/Uploads/A-Focus-on-Provider-Quality-Jan-2015.pdf https://www.humana.com/medicare/ad/humana-at-home https://www.humana.com/medicare/ad/humana-at-home or she has needed skilled nursing care.