These patients, considered many of who are frail, can unwittingly fall through cracks, as they require different levels of service. This can be extremely stressful on both the patient and the patient's family, as the patient moves between different levels of care.
Care can become fragmented and lead to problems that impact the patient's wellbeing.
This program is an intensive effort to assist patients and their families as they go through the continuum of care, through enhanced communication between the patient, family, and all providers of care. Patients are followed from the moment they are transferred to the hospital. All aspects of the patients' care are coordinated by the Geriatric Care staff, from admission to discharge, and follow-up. There is a complete assessment of the patients' healthcare needs, as soon as the patient is admitted, no matter how the patient is brought into the hospital. The Geriatric Care Management Program provides referrals to other resources in the community.