What Is Home and Community-Based Care?

Home and community-based care includes medical, supportive and wellness services delivered in the home or outside traditional healthcare facilities. These services help people recover from illness, manage chronic conditions, receive comfort-focused care and remain engaged in daily life while maintaining independence.

Care may be short term or ongoing and is tailored to individual needs, goals and preferences.

Who Can Benefit From Home and Community-Based Care

  • People recovering after a hospital stay or surgery

  • Adults managing chronic or complex health conditions

  • Individuals who need medical or supportive care at home

  • Older adults who benefit from social engagement and supervision

  • Patients and families seeking comfort-focused or end-of-life care

THE CARE WE PROVIDE

Home Health Care

Medical care provided in the home for individuals recovering from illness, injury or surgery, or managing a chronic condition. Services are delivered by licensed health professionals and include the following:

Skilled Nursing Care

Licensed nurses provide a variety of nursing care including wound care, medication management, disease monitoring, injections, IV therapy and patient education in the home.

Rehabilitation Therapy

Physical, occupational and speech therapy services to support recovery, restore mobility and improve daily function.

Chronic Disease Management

Ongoing monitoring and education to help patients manage conditions such as heart disease, diabetes, COPD and other chronic illnesses.

Medical social work and care coordination

Support with community resources, discharge planning and navigating complex medical needs.

Nutrition Counseling

Personalized dietary guidance to support healing, manage chronic conditions and promote overall health.

Obstetric and Maternal Services

Home-based prenatal and postpartum care for mothers who need additional monitoring and support.

Palliative and supportive care

Symptom management and comfort-focused support delivered in coordination with providers and specialists.

Hospice care

Hospice care provides comfort-focused support for individuals living with a life-limiting illness. When treatment shifts from cure to comfort, our goal is to help patients live as fully as possible, with dignity, peace and control over their care.

Pediatric services

Skilled home health services for infants and children with medical needs, including newborn assessments, injections, infusion therapies, wound care and enteral and parenteral feeding needs. Pediatric services are delivered in coordination with pediatric providers.

Pharmacy, infusion therapy and drug monitoring

Medication review and monitoring to ensure prescriptions are taken safely, prevent interactions and support effective treatment at home.

Telehealth

Secure virtual visits and remote monitoring that expand access to care and support early identification of concerns. The goal of home health care is to help patients recover safely, maintain independence and avoid unnecessary hospital visits while receiving care in the comfort of home. Includes:

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Adult Day Services

The Ralph C. Wilson Jr. Adult Day Services at North Tonawanda provide structured daytime care and supervision for adults who need support with medical needs, daily activities or cognitive conditions. The program offers social engagement, therapeutic activities and health monitoring in a safe, supportive setting.

Adult day services also provide respite for caregivers, giving families peace of mind while their loved ones receive compassionate care and meaningful interaction during the day. 

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Home visits

When patients are unable to travel to their primary care physician’s office, care can come to them. Designed for individuals who are high-risk or homebound, home visits extend primary care services into the home setting.

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How Your Care Comes Together

A comprehensive evaluation. Your care team assesses medical needs, home or community setting considerations and personal goals to determine the right level of care.

A personalized care plan. Care plans are developed with you, your family and your provider, and adjusted as needs change.

Ongoing support and coordination. Our teams work closely with Kaleida Health hospitals, physicians and community partners to ensure seamless, coordinated care.

Why Patients Choose Kaleida Health for Home-Based Services

  • Trusted care from Western New York’s leading health system

  • Coordinated services across the continuum of care

  • Experienced, compassionate care teams

  • A focus on dignity, independence and quality of life

Getting started

How do I request care?

You can request services by contacting our care team, speaking with a hospital discharge planner or asking your primary care provider for a referral.

What insurance plans are accepted

We accept most major insurance plans, including Medicare and Medicaid. Coverage varies, and our team can help explain your options.

Take the Next Step In Your Care