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 all of the 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 a 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, emotional, spiritual, 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 understand 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
- Identifying other resources that can assist patient and/or care giver
- Completing a health care directive, power of attorney, etc.
- Creating an individualized care plan that:
- Supports the goals set by the patient and primary care giver
- 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, including 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 care taker 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