| http://www.w3.org/ns/prov#value | - spital discharge follow up and care;Liaises closely with physicians and hospitals regarding post-hospital discharge care and treatment;Identifies factors that may interfere with or impede a client???s ability to be as independent as possible and initiates appropriate actions, such as referrals to address the concern;Provides information and teaching to clients and caregivers regarding self-care, w
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