New medical diagnosis needing teaching
Falls or near falls; balance problems
Following hospitalization or inpatient rehabilitation stay
Following discharge from skilled nursing facility
After an E.R. visit or Urgent Care visit
Fluctuations in diabetes or blood pressure
Changes in primary caregiver with need for teaching
Uncontrolled pain
Difficulty with breathing
Changes in medication regimen or new medications within the last 60 days
Uncertainties about overall medication management
Worsening medical conditions
Wound care
Changes in appetite, difficulty swallowing
Change in independence with activities of daily living
Difficulty self-managing cancer treatment side effects