How It Works

Our Integrated Care Program provides specialized medical and emotional support for patients living with a serious illness, and includes a Nurse Practitioner and Social Worker to support patients in the comfort of their chosen setting. By helping patients to navigate the complex health care system through better planning, access to resources, and hands-on support, we keep patients on their path to recovery.

  • Anyone can refer a patient to the Integrated Care Program
  • Settings of care can include patient or family home, skilled nursing facilities or adult residential care homes
  • There is no set amount of time patient is on the program, but will re-evaluate every 90 days

Support Services

  • Nurse Practitioner and Social Worker support
  • Advance care planning
  • Meetings about patient and family goals of care
  • Emotional Support
  • Assistance with applications, filling out forms, etc.
  • Disease process monitoring and education
  • Community education
  • Referrals to additional community resources
  • 24/7 phone support

Admission Criteria

  • Reduced ambulation, significant disease, occasional self-care assistance needed, normal or reduced intake, full or confused conscious level
  • Cancer Stage III or IV
  • CHF (Congestive Heart Failure)
  • COPD (Chronic Obstructive Pulmonary Disease)
  • ESRD IV or V (End-Stage Renal Disease)
  • Parkinson’s Disease, Dementia or ALS with
    functional decline, weight loss, and/or increasing
    dysphagia