Continuum of Care

Montefiore's Ambulatory Care Center encompasses adult and pediatric specialty care and one primary care clinic. The Center has a significant teaching mission. Our ambulatory care nurses also work closely with nursing professionals from acute care areas and share their nursing policies and practices to ensure the continuum of care.

The Montefiore Medical Group is a network of primary care offices throughout the Bronx and Westchester. We place an emphasis on strong partnerships among the interdisciplinary team members and the community.

Primary care clinics at the Moses Division provide care for adult, pediatric, obstetrical/gynecological and adolescent patients. Our onsite interdisciplinary care includes the services of physicians, nurses, social workers, nutritionists, HIV counselors and health educators.

In addition to gaining experience with a strong emphasis on personalized care, Montefiore's primary care nurses become skilled in research, interviewing and marketing. Our emphasis on comprehensive patient histories fosters outreach to the patient's family members and community by engaging them in the healthcare process. 

Clinical Care

Our dedicated, highly trained registered nurses work closely with health educators and counselors in all specialty clinics and at all levels of care. In addition, our nurses serve beside the skilled and experienced Albert Einstein College of Medicine faculty.

Montefiore Home Care

The Montefiore Home Care nurse functions autonomously in conjunction with the physician's plan of treatment to provide coordinated skilled services to patients at home.

The Certified Home Health Agency (CHHA) provides short-term illness management, including infusion therapy for post-hospital recuperation, or for patients in the community who require acute care. The Home Care nurse is responsible for providing a plan of care, which encompasses the family system as well as the environmental, cultural, psychosocial and educational needs of the patient. 

The Long-Term Home Healthcare Program, often referred to as the hospital without walls, provides home visits to chronically ill patients. The program includes coordinated skilled nursing, patient education, health promotion and nutrition services.

The Telecare Program provides 24-hour electronic access to emergency assistance, a service that often enables the frail elderly to remain at home. By reporting their weight and vitals daily into a computerized system that is attached to their phone line, patients learn how to manage if not improve their health and maintain their independence.