Transitioning Home

We understand that the world of health care can seem overwhelming.  For that reason, our Case Managers and Social Workers will work closely with you and your family to help you transition from CVPH to your home or another more appropriate setting as quickly, smoothly and safely as possible.

Our Nurse Case Managers and Social Workers have expertise in a broad range of health care-related issues and can help you plan for your continuing care creating a personalized plan:

• Arranging for Home Care Services
• Arranging for Rehabilitation 
• Arranging for Skilled Nursing Facilities
• Connecting you with community resources and benefits programs
• Working closely with physicians and other team members to ensure you have the appropriate services and they are covered by your insurance plan

Contact Case Management

Please call (518) 562-7395 and ask for the Case Manager or Social Worker on duty.
 

Transitional Care Nursing

Transitional Care Nursing focuses on the coordination and continuity of health care when you move from one health care setting to another or home.  During care transitions, patients with complex medical needs are at an increased risk for medication errors, communication gaps from facility to facility and between primary care providers, specialists and patients/family/caregivers.  The Transitional Care Nurse assists with bridging any gaps that may occur during a care transition, ensuring better health outcomes.  The nurse can provide you with tools and support that promote knowledge and self-management of your conditions to help prevent readmission.

If you’re in need of transitional care, your Care Manager will meet with you prior to leaving the hospital to discuss care management services.  In the event your Care Manager is unable to meet with you prior to discharge, they will reach out to you with a follow-up call.

Community Services

We encourage you to visit New York Connects online to learn more about the array of community services, providers and resources throughout New York's Clinton County for seniors, families, caregivers and care managers.  In addition, there are many local agencies that can help you at home or provide other services based on your needs including: