The traditional model of nursing, in which patients are discharged with a follow-up medical appointment, is no longer sufficient in the current healthcare environment. Primary nurses working in a 58-bed rehabilitation unit located in a 1,700-bed tertiary care medical center implemented a follow-up telephone call program to support the patient's transition from acute rehabilitation nursing care to community living. Patients discharged to home within a five-state area were called 2 weeks and 6 weeks after discharge. Notes on the telephone conversations were entered on a data collection form and later analyzed using Orem's self-care deficit theory (Orem, 1991). A total of 144 follow-up calls were made. During the first call (n = 105), 157 problems (1.5 per call) were noted, whereas 79 (2.0 per call) were identified during the second call (n = 39). Medication, safety, and bladder problems were most often cited as concerns by patients and caregivers after discharge. The most frequently used helping interventions during both the first and the second telephone calls were guiding and supporting.