Continuum of Care

Ambulatory and Primary Care

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

The Montefiore Medical Group is a network of primary care offices throughout the Bronx and Westchester. Emphasis is placed on a strong partnership among the interdisciplinary team members and the community.

Primary care clinics at the Moses Division provide care for adult, pediatric, prenatal, obstetrical/gynecological, and adolescent patients. Each benefits from on-site interdisciplinary care which, in addition to physician and nursing services, may incorporate the skills of social workers, nutritionists, HIV counselors and health educators. In addition to nursing practice with a strong emphasis on personalized care, Montefiore primary care nurses are skilled in research, interviewing and marketing. The emphasis on taking comprehensive patient histories fosters outreach to family members in the community to engage them in the health care process. 

Clinical Care

Nursing support at all levels is essential to Montefiore medical specialty clinics in which dedicated, highly trained RNs work closely with health educators and counselors. In addition, faculty from the Albert Einstein College of Medicine serve as preceptors, offering a wealth of educational opportunities.

Home Health Care

The Montefiore Home Health Care Agency 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 Health 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 identified patient. 

 The Long Term Home Health Care Program, often referred to as "The Nursing Home Without Walls," provides home visits to chronically ill patients. This includes coordinated skilled nursing, patient education, health promotion and nutrition.

The Telecare Program provides 24-hour electronic access to emergency assistance, a service that often enables the frail elderly to remain at home.