Paula went to meet with a patient to initiate home care services. Upon speaking with the patient, she realized that due to homebound status and the patients decision to not pay out of pocket for skilled services, she would be unable to complete the start of care or take the patient onto our service. However, Paula recognized the patient still had multiple needs. She called his physician and fully explained his immediate needs and assisted the physician to set up out patient physical therapy to begin within the week. This took several calls to manage. Paula also called our medical social worker and requested a list of potential community resources be sent to this patient and family. She went on to call our Independent Care Services department per the wife's request and set up an in home meeting for the same day. Paula spent the time needed to assist this patient and his wife despite him not being appropriate for our skilled care. She went above and beyond to ensure his needs would be met in the community.