Two unique programs of Crouse Hospital's Aging & Complex Care Services help senior patients make successful transitions from hospital to home.
Healthcare Partners
Clinical experts from a variety of medical disciplines are needed to adequately address the needs of patients with chronic diseases such as diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Our Healthcare Partners Program brings together experts in clinical pharmacy, nutrition, physical therapy, care coordination, diabetes education, respiratory therapy, palliative medicine and geriatric medicine and geriatric nursing to work collaboratively to address patients’ complex care issues.
Care Transitions
Upon discharge from the hospital, many senior patients still require support. Crouse's Care Transitions Program coaches patients in taking the lead in managing healthcare issues after discharge to prevent a return trip to the hospital, while maintaining and improving the patient’s overall health.
A specially trained nurse follows a patient from the inpatient bed to discharge, and stays in contact with the patient at home or by phone until the patient feels comfortable with self management. By understanding specific medical conditions and needs, the transition nurse can help patients monitor medications, maintain physician follow-up and know the signs and signals necessary to effectively manage chronic conditions.