VNA of Albany delivers specific care programs that support patient teaching, positive patient outcomes, care transitions, and hospital/ER admission avoidance. Our programs are coordinated for patients by a VNA clinical case manager, who practices under the direction of physician’s orders.
VNA of Albany programs include: Asthma Program, Transition Coach Program and Sub-Acute Transition Program.
VNA of Albany’s Asthma Education Home Visit Program provides assessment, monitoring and education for patients who have poorly controlled asthma and who have had recent hospitalizations and/or emergency room visits due to their asthma. The program is designed to assess the patient and their environment, monitor treatment and effectiveness, and educate patients and their caregivers on disease process, environmental triggers, and self-management.
Transition Coach Program
The goal of the Transition Coach Program is to empower patients and families through an effective transition from the hospital to their home. Our VNA Transition Coaches are registered nurses who meet with patients in the hospital to assess their understanding of their disease, assess the availability of supports at home, and ensure there is transportation available for medical appointments and prescriptions. The Coach will meet with the patient at home shortly after discharge to provide education focusing on medication management, follow-up physician appointments, identifying red flags, and maintaining a personal health record. Within a few weeks, the Coach will conduct a follow-up phone call to check on the patient’s status.
Sub-acute Transition Program
Through our Sub-acute Transition Program, patients are effectively transitioned from the hospital to a sub-acute/Skilled Nursing Facility (SNF), and then to VNA home care. Patients who participate in the program are met by VNA Home Care Nurse Coordinators in the hospital prior to their discharge to the SNF to discuss their transfer to the facility, and then to home care. A VNA Clinical Liaison Nurse coordinates with the Social Work staff at the SNF upon admission of the patient, and meets with the patient during their stay in the facility to prepare them for discharge to VNA home care.
For more information on VNA of Albany programs or how to start services and to initiate a referral, please click here.