Integrated Care

Integrated Care

Our Integrated Care Program provides specialized medical and emotional support for patients living with serious illnesses.

Our integrated Care Program is comprised of a dedicated team that includes a Social Worker and an Advanced Practice Registered Nurse to assist patients who need help finding solutions in their time of need. Patients can also seek curative treatments while in our Integrated Care Program.

Integrated care is not hospice care; it is designed to alleviate the pain and challenges patients face—both physical and emotional—when living with a serious condition.

Support Services

We’re proud to offer the following wide range of services to provide emotional and physical relief for patients with serious illness:

  • Social Work and Advanced Practice Registered Nurse (APRN) support
  • Advance care planning
  • Meetings about patient and family goals of care
  • Emotional support
  • Assistance with paperwork
  • Disease process monitoring and education
  • Community education
  • Referrals to additional community resources

How It Works

  • Anyone can refer a patient to the Integrated Care Program
  • Patients must be living in specific geographic regions (call for details)
  • Settings of care can include patient or family home, skilled nursing facilities or adult residential care homes

Admission Criteria

  • PPS or 60 or less and at least one of the following:
    • 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)
  • Neurodegenerative disease with functional decline, weight loss, and/or increasing dysphasia

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