Complex Care Management
As part of an ongoing effort to provide comprehensive, high-quality care, the Brookdale Department of Geriatrics and Palliative Medicine has instituted innovative programs designed to address the unique health needs of older adults and their caregivers. These programs improve care coordination, reduce the number of emergency room visits and hospital admissions, and enhance your experiences with our health care system. Our teams include a geriatrician, physician fellows specializing in geriatrics and palliative care, a geriatrics nurse practitioner, geriatrics social worker, care coordinator, and administrative assistant.
ALIGN
The ALIGN (Aging, Life Innovations, Goals and Needs) team ensures that older adults with complex medical illnesses have a comprehensive health care plan that addresses all of their unique needs. We partner with you, your caregivers, and your existing medical teams to achieve a shared understanding of your health care goals and, together, we create a care plan to match those expectations.
The ALIGN team works with individuals for several months to stabilize acute medical and social work challenges alongside your primary care team at the Martha Stewart Center for Living Uptown.
In addition to coordinating your care with other physicians, we will make sure you and your caregivers have the resources needed to carry out your doctor’s recommendations. We monitor medications, help establish a health care proxy if appropriate, ensure your understanding of the care plan, and provide guidance to caregivers. We also offer a 24-hour hotline to answer any questions, provide coaching when necessary, and allay patient and family concerns.
If you have highly complex medical conditions, frequent hospital visits, or inadequate caregiver support, please ask your primary care provider about our services.
To make a referral, providers should send an EpicCare Ambulatory Referral to ALIGN High Risk Geriatrics or call 212-659-8552.
Contact Info:
Martha Stewart Center for Living
17 East 102nd Street, 4th Floor
New York, NY 10029
Phone: 212-659-8552
ALIGN-CARE
The ALIGN-CARE (Collaboration Achieving Readiness and Empowerment) team partners with you, your caregivers, and your existing medical teams to provide an added layer of support before, during, and after surgery. Because research has shown that older adults may have higher rates of post-operative complications, our team takes thoughtful care to reduce any modifiable risk factors in your health. When approached by a surgeon for assistance, we conduct a comprehensive review of your unique needs and concerns. This review includes medical and social assessments to see if surgery is right for you. We offer functional and cognitive screening, nutritional guidance, recommendations to optimize medications for chronic health conditions, and seek to strengthen coordination services if needed.
The impact of ALIGN-CARE on the surgery and clinical care that both precedes and follows can be considerable. Surgical patients guided by ALIGN-CARE receive specific geriatrics medicine and social work recommendations to reduce risk and optimize your ability to be the best possible surgical candidate.
What makes the Mount Sinai program truly different from other co-management programs around the country in that our approach is to reach our patients earlier in the pre-surgical planning process, which could occur weeks before the actual surgery, allowing for more time to stabilize and improve overall heatlh outcomes. You will meet with ALIGN-CARE specialists the Martha Stewart Center for Living Uptown, and we will work closely with your primary care team and surgeon to ensure best possible communication among all of your providers. To make a referral, providers should send an EpicCare Ambulatory Referral to ALIGN-CARE Geriatric Surgery Co-Management Program or call 212-659-8552.