Problem: Discharge needs/criteria (i.e. supplies/equipment, home health, mhsu, patient/family, medical functional social needs etc.) for Betty who was admitted to hospital with chest pain, dyspnea and worsening peripheral edema. Betty has a hx of 2 MIs, one in 1996 and one more recently in 2015. She had a right-sided CVA in 2017. Betty also has a 20-year hx of atrial fibrillation and hypertension.