Cardio-Pulmonary Disease Management Program
Congestive heart failure (CHF) and cardio-pulmonary disease (COPD) often have a high rate of re-hospitalization. Our successful plan to help our patients live comfortably at home and decrease avoidable hospitalizations includes:
- 911 Guidelines: Guidelines were developed for 15 common diagnoses to help patients determine when to call 911 and when to call the VNA if they experience health problems.
- Management of patient visits: We make more frequent visits at the start of care to conduct enhanced education on the disease process as well as intensify the assessment.
- Telemonitoring: Use of telemonitor units are standard for all patients diagnosed with cardio-pulmonary disease. The units are placed in the home and allow patients to take vital signs daily and transmit them in real time to a station manned by a nurse in our office.
- ZOE Fluid Status Monitoring: A ZOE Fluid Status monitor may be placed in cardiac patients' homes. The device allows the patient to measure pulmonary fluid status on a daily basis.
- Sliding Scale Dosing: We request a physician's order for "sliding scale" dosage for diuretics.
- Patient Handbooks: Disease Management Handbooks were written and designed by our education team with elderly patients in mind. They include:
- Medication Teaching Tools: Patient specific medication cards developed to highlight the most important med management issues.
- Nutritional Support: teaching of low sodium diet by certified dietician
