Visiting Nurses Home Health

The Perfect Balance of Healing and Home

Visiting Nurses Home Health offers skilled nursing services and specialty care to patients in New York’s Capital Region.

Referrals to Visiting Nurses Home Health must be initiated by a patient’s primary care physician or specialist, or by a physician at a hospital or skilled nursing/sub-acute care facility. More information on initiating referrals can be found here [link when live]. Our services and programs are coordinated for patients by a Visiting Nurses clinical case manager, who practices under the direction of physician’s orders. Find more information on initiating a referral.

We deliver specific care programs that support patient education, positive outcomes, care transitions, and hospital admission avoidance. We provide a wide range of services that can be explored below.

Programs and Services

We provide skilled intermittent care at home to patients who have recently been discharged from a hospital, skilled nursing facility, or sub-acute facility. We also provide care to people who have a new diagnosis or multiple diagnoses, one or more chronic illnesses, change in medications, wound care needs, or those who requires education or monitoring at home between physician visits.

A case manager will develop an individualized care plan for each patient based on an assessment during the initial visit.

More information on our programs and services can be found below. In addition, we offer patient review for nursing home placement, medication management, and health education.

The Albany Med Health System Visiting Nurses provides rehabilitation services including physical therapy, occupational therapy, and speech language pathology to patients who are recovering from surgery, have pain, deconditioning, or any type of cardiopulmonary, neuromuscular, neurological, or orthopedic deficit.

Our clinicians assess patients using industry-accepted fall risk assessment tools and implement a home safety and falls prevention program with all our patients. Based on the scores in these assessments, goals are established and interventions are identified. The therapist may implement intensive targeted interventions such as exercises, safety measures, adaptive or supportive equipment evaluation, recommendations for vision, hearing, or swallowing adaptations, medication reviews and follow-up, home environmental review and recommendations, teaching tools, and community resource identification.

Physical therapy

  • Home safety and falls reduction program
  • Restorative exercises
  • Transfer skills
  • Ambulation training
  • Equipment use
  • Patient and caregiver education

Occupational therapy

  • Independence with activities of daily living
  • Personal energy conservation
  • Adaptive equipment training
  • Stress management

Speech language pathology

  • Communication skills
  • Rehabilitation
  • Assessment and treatment of swallowing disorders
  • Techniques for memory recall

Our nurses provide oversight and care for patients who have active wounds or the potential for active wounds as the result of surgery, skin breakdown, disease, or injury.

Patients with a diagnosis of congestive heart failure, COPD, asthma, CAD, and chronic pneumonia benefit from the expertise of our registered nurses, who provide clinical care as well as educate patients and their caretakers regarding how to recognize signs, symptoms, and red flags of their cardiopulmonary disease.

Our asthma education home visit program provides assessment, monitoring, and education for patients who have poorly controlled asthma and have had recent hospitalizations 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.

Our nurses can deliver infusion therapy for treatments such as antibiotics, intravenous fluids, chemotherapy, ionotropic agents, corticosteroids, opioids, and total parenteral nutrition (TPN).

Our nurses have expertise in diabetes management and prevention. They educate and support patients affected by diabetes by teaching them how to understand and manage their condition in order to achieve individualized behavioral and treatment goals. Our registered nutritionist assists with education to help patients maintain a proper diet.

Our medical social workers provide counseling and advocacy to patients about medical limitations, community resource education, and long-term planning. They are an integral part of the Visiting Nurses’ interdisciplinary team of care providers. Medical social workers perform a comprehensive assessment of the patient’s social, emotional, environmental, and financial needs to help them and their families alleviate the hardships related to adverse health conditions. They also provide education on entitlements, community services, and health insurance coverage. View this brochure to learn more.

Our palliative program focuses on quality of life, providing relief from pain and other symptoms, maintaining maximum degree of function, augmenting support systems to help patient and caregivers with emotional issues and improving patient's ability to cope with treatment demands.


Through our sub-acute transition program, patients are effectively transitioned from the hospital to a sub-acute/Skilled Nursing Facility (SNF), and then to Visiting Nurses Home Care. Patients who participate in the program are met by Visiting Nurses 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 Visiting Nurses 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 Visiting Nurses Home Care.

Albany Med Health System Visiting Nurses
35 Colvin Avenue
Albany, NY 12206

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