Certified Home Health Agency Since 2014

Chronic Disease Management Program

Who do we seek to serve through this program?

We seek to serve individuals who have a chronic illness/disease that is not going to go away, is likely to progress with time, and is likely to contribute to end of life at some point.

We believe those who may benefit most from this program are those who:

May struggle at times to manage symptoms and/or may become overwhelmed at times with the many aspects involved in managing a chronic illness/disease
Have struggled to maintain health stability in recent weeks/months
May have experienced multiple trips to the ER/Hospital or Urgent Care in recent weeks or months
May have experienced a notable decline in their illness/disease recently
Seek the support of an ongoing care team and/or have a primary care taker that may benefit from the support of a care team

Developing a Care Plan

In creating a care plan for Chronic Disease Management patients, the assessment would include a focus on:

General assessment – health, well-being, support systems, community resources, etc.
Determining where the patient is in their disease progression
Determining what aspects of the disease we may or may not be able to affect/impact at this point (what areas do we think we can help to improve and what areas are likely to be difficult to improve, given the disease progression, etc.)
Determining what aspects of managing the illness/disease has been most challenging or is likely to continue to be challenging
Determining specifically what the patient/primary care giver’s goals are in the short and long term. Goals may include things like:

  • Enhance care coordination among various health care providers
  • Remain living at home
  • Reduce trips to the ER/Hospital/Urgent care
  • Reduce stress on primary care giver
  • Improve medication management and/or compliance
  • Become more educated about the illness/disease; develop a better understanding of the disease and what to expect as it progresses; and create plans for how the patient wishes to address potential situations that may arise throughout the disease progression(Ex: what is plan B if I can no longer remain living at home?)
  • Develop tools for enhancing self-management skills
  • Identify other resources that can assist patient and/or caregiver
  • Complete a health care directive, power of attorney, etc.

Create an individualized care plan that:

  • Supports the goals set by the patient and primary caregiver
  • Meets with the approval of the patient’s primary care provider
  • Identifies an interdisciplinary care team to implement the patient’s care plan
  • Seeks to maintain health stability as much as possible, for as long as possible
  • Includes educational components, such as self-management strategies

Other Components of our Chronic Disease Management Program

We seek to take an interdisciplinary approach to supporting patients in our Chronic Disease Management program, based on our assessment of the patient’s needs.
We seek to provide support to the patient, as well as the primary caretaker and/or family.
The Chronic Disease Management services and supports we provide are intended to be ongoing in nature. That is, while we may be asked to provide services initially because the patient is struggling, our goal would be to continue to support the patient, even after they have reached a level of stability - in hopes of helping the patient to maintain that stability as much as possible and for as long as possible throughout their disease.

A patient may receive services through our Chronic Disease Management Program:

While receiving Home Health services as part of an eligible Home Health episode
Following completion/discharge from an eligible Home Health episode
Even if they are not receiving Home Health services as part of an eligible Home Health episode