An outpatient program designed to help patients safely transition from hospital to home and community * coordinated health services and rehabilitation for people recovering from functional decline due to recent injury or illness * services may include medicine, nursing, occupational therapy, physiotherapy, speech language pathology, and therapeutic recreation * goal of the program is to give patients and families the knowledge and skills to safely manage their health and to help patients successfully re-integrate into their community

• individual assessment of functioning at home and in the community
• custom treatment plans to help patients in their recovery
• enhancement of physical, cognitive, functional, and psychosocial skills
• education for patients and their families to help improve their coping skills, maximize potential and optimize function
• development of skills leading to successful community integration
• support in maximizing independence in the community and liaison with community support systems, especially the Next Step to Active Living Program