This interdisciplinary team, comprised of nurses, home health aides, social work, physical therapy, occupational therapy, and speech language pathologists, enters patients' homes every day with the goal to improve their health, quality of life, and decrease their readmissions to the hospital. Unlike being in an office or a facility where the patient comes to the providers, this staff enter patients' homes unknowingly to what they may encounter with the most cheerful disposition, treating patients with dignity and respect while conquering obstacles presented by various social determinants of health (SDOH).

Patients are treated in acute care during hospital stays, in comprehensive inpatient rehabilitation, and in skilled nursing facilities to regain strength and to treat or cure an illness. When patients return home, they often face barriers such as chronic illness management, managing new home medical equipment or devices, performing wound care, performing catheter management, IV therapy management, ostomy care, prosthesis, and the list could go on and on. This team educates the patient and or their caregiver and finds a bridge for outpatient follow-up upon discharge.

In addition to health-related concerns, patients often struggle with navigating their home environment, poor living environments, financial insecurities, food insecurities, and transportation issues that prevent them from returning to needed appointments. This team is there to help with it all! Looking at each individual, their situation, and offering a resolution. They surpass the values of excellence and innovation when working collaboratively to find solutions for patient care, offering resources available through UPMC and various partnerships within the community. Therapies, nursing, and social work often find individualized solutions for patients to receive the care they need and to find ways for the patient or caregiver to perform needed self-care at home or for transportation services to appointments. This team is comprised of the most compassionate and innovative members who are truly making a positive impact on the community that we serve. Patients often thank the staff for their time, care, and commitment, and the common response is, "I was just doing my job." Without these caring individuals many patients would go without the needed in-home therapies, follow up, education for management of disease processes, and medication education that they need to continue to thrive in the community.