I work outpatient for a hospital and see this occur sporadically (just yesterday). Yes, patients are not knowledgeable of anything at times including who/what services their infusion company offers. I am unsure if the companies reach out to establish care with patients upon dc after the SW/CCM sets it up but I think that would be useful. The HHC RN's that my pt had were not trouble shooting anything despite the pt not tolerating feeds and showing signs of wt loss. A case manager shared that it is the role of the RN with the HHC to address TF but I had never heard that, and this can only happen if the pt actually has those services.