As an RN who worked in home care, comm health and hospice when I read the stuff about coordinating care I laugh. This is what RN case managers do and have done for years and years. It's not a new model. We just don't offer Vitamin C. 
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When my son was sick with colon cancer, aside from the fact I was a hospice nurse at the time, we would have declined this conversation. This care is usually available with coord between hosp SW and home care team.
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