Capital District Internal Medicine

Our Approach: Coordinated Care

We bridge the gap by connecting:
• Primary care physicians (PCPs)
• Specialists
• Home Health providers
• Patient and family support teams
Goal: Prevent readmissions by ensuring smooth, informed, and supported transitions

Why Transitions of Care Matter

Smooth care transitions can dramatically improve patient outcomes by:
• Enhancing quality of care
• Reducing preventable readmissions
• Ensuring patients receive timely follow-up

Focus on High-Risk Patients

Ideal for individuals who:
• Have complex or chronic conditions
• Are at high risk for readmission
• Lack timely follow-up with a PCP

Nurse-led interventions include:
• Medication review
• Patient education
• Personalized care plans
• Telemedicine availability

Advanced Practitioner (AP)
Training Program

This site also serves as a training program for APs. The program is designed to foster professional growth, enhance performance, and improve quality of care,cost of care, and effectiveness of care.