title: Mobile teams fill the gap between the hospital and the community.
abstract: A clinical team from The Valley Hospital in Ridgewood, NJ, visit at-risk patients at home after discharge if the patients don't qualify for or refuse home health services. A mobile team that includes a paramedic, a critical care nurse, and an emergency medical technician visits patients who have been referred by the case managers after a risk assessment. The team performs a comprehensive assessment of the patients and their home situations and reinforces the discharge teaching they received in the hospital. In most cases, the team makes only one visit but will return if the patient still needs support.
mesh_terms: D019033:Delivery of Health Care, Integrated; D006764:Hospitals, Community; D008952:Mobile Health Units; D009515:New Jersey; D019982:Organizational Case Studies; D010348:Patient Care Team