Outreach Chronic Care Nursing

Chronic Care Department

Phone: 518-358-3141 x2017

Fax: 518-358-2493

On-call Nurse Cell: 518-481-4154

The Saint Regis Mohawk Tribe Chronic Care Department provides coordinated, compassionate services designed to support individuals with ongoing health needs and complex care challenges. Our goal is to promote stability, independence, and healing by delivering care that respects the whole person—body, mind, and spirit—within the context of family and community.

This department brings together clinical care, supportive services, and practical assistance to ensure seamless transitions across settings such as hospital, home, and community-based care. Services are delivered by skilled nurses, care coordinators, aides, and transportation staff who work collaboratively with patients, families, and other SRMT Health Services programs.

Services Offered

• Chronic Disease Management and monitoring
• Case Management and Discharge Planning
• Home Health Aide Services
• Complex Foot Care
• Wound Care
• Medical Transportation
• Immunizations & Wellness Screenings
• Lab Draws and Specimen Collection for Homebound Patients
• Medication Management
• Lifeline Setup
• 24/7 On‑Call Support (Home Care Patients Only)

Criteria for Services

To be eligible for Outreach services, patients must:

• Be currently enrolled and under the care of a primary care provider at SRMHS
• Be seen by their primary care provider at least once per year
• Have a consult or referral from their primary care provider for all services

Home Healthcare Services

A nurse will complete an initial home visit to assess the patient’s medical needs and functional abilities. During this visit, the nurse and patient will identify unmet needs and work together to develop a personalized care plan based on individual goals.

The care plan outlines the number of service hours required and how home health aides will assist with daily tasks. Home health aides may provide support with:

• Personal hygiene
• Light housekeeping
• Meal prep
• Vital sign monitoring
• Medication reminders
• Daily exercises

We offer:

• Long‑term home care
• Short‑term post‑operative care
• End‑of‑life hospice support
• Respite Care

Complex Foot Care

In collaboration with the Diabetes Center, Chronic Care staff provide education on proper foot care to help maintain healthy skin integrity. 

• High‑risk diabetic foot care (History of Diabetic Foot Ulcers)
• Complex non‑diabetic foot Nail care
• Callus and corn debridement
• Ankle‑Brachial Index (ABI) testing

Wound Care

Our Certified Wound Care Nurses stay current with best‑practice wound care standards and work closely with your healthcare provider to deliver skilled, comprehensive treatment plans. Care is designed to promote healing, restore daily functioning, and improve quality of life. All wound care services are provided locally, helping reduce the burden of travel to outside facilities. 

Medical Transportation

Handicap‑accessible vehicles are available to transport patients to and from medical appointments and procedures. Transportation services are offered to all of the local medical facilities. Requests for appointments outside this area will be reviewed on a case‑by‑case basis. Transportation requirements:

• A confirmed referral to a medical specialist is required
• Requests must be made at least two weeks in advance.
• Patients having sedation must have a responsible caregiver who is at least 18 years old to receive them when they return home.

Our team focuses on continuity of care, patient education, and proactive planning to reduce complications, prevent hospital readmissions, and support long-term wellness. By working closely with medical providers, caregivers, and community partners, the Chronic Care Department helps patients navigate their care with dignity, respect, and confidence.

Please contact the department for more information or to discuss care needs.