Welcome to the Extensivist Program

  • A unique and innovative service that provides personalized and comprehensive care for patients who have recently been discharged from the hospital.
  • Our goal is to help you recover faster, prevent complications, and avoid readmissions.
  • The Extensivist Program is designed for patients who have complex medical needs and require close follow-up after hospitalization.
  • Our team of experienced and compassionate health professionals will work with you and your primary care provider to create a customized care plan that meets your specific needs and preferences.

As part of the Extensivist Program, you will receive

  • Weekly visits from our extensivist nurse, who will monitor your health status, provide education, and coordinate your care. The visits can be done virtually or at your home, depending on your preference and availability.
  • Access to our extensivist physician, who will oversee your care plan, manage your medications, and address any urgent issues that may arise. The physician can be reached by phone or video call at any time, 24/7.
  • Support from our extensivist social worker, who will assist you with any psychosocial or practical challenges that may affect your recovery. The social worker can help you with accessing community resources, arranging transportation, applying for benefits, and more.
  • Connection to our extensivist pharmacist, who will review your medications, ensure their safety and effectiveness, and answer any questions you may have. The pharmacist can also provide medication delivery and adherence support, if needed.

The Extensivist Program lasts for four weeks after your discharge from the hospital. During this time, we will work closely with you to help you achieve your health goals and improve your quality of life. We will also communicate regularly with your primary care provider and other specialists to ensure a smooth and seamless transition of care.