Potential subjects will be identified from i) inpatients referred prior to discharge and ii) outpatients to medical social workers from Singapore General Hospital (SGH) and Alexandra Hospital (AH). After confirming study eligibility the medical social worker will inform the potential subject about the study; after obtaining informed consent, the medical social worker will make a telephone call to the Duke - NUS research fellow who will then carry out the randomization process, assigning the subject to either the intervention group or the control group.