Skilled Nursing Disease Management Program

Our Skilled Nursing Disease Management Program

(Also for Providers participating in Accountable Care Organization)

 

DIABETES MANAGEMENT PROGRAM

Outcome Criteria – HbA1C is maintained at an acceptable value.

Our nurse will:

provide outpatient education, implement dietary control and exercise measures with a high level of care coordination.

 

HOSPITAL READMISSION REDUCTION PROGRAM

Outcome criteria – Reduction of hospital readmission within 30 days of an acute care hospitalization

Our nurse will conduct:

¨ Timely quality clinical follow up

¨ Improved care coordination with discharge planners and transition care managers

 

ASTHMA MANAGEMENT PROGRAM

Goal: To prevent rehospitalizations of pediatric and adult patients

Outcome criteria – Asthmatic symptoms are controlled and manage on an outpatient basis.

Our nurse will:

Provide timely home visits to provide clinical assessment, asthma trigger recognition and education, with appropriate referrals to control and reduce clinical symptoms

 

CARIDAC DISEASE MANAGEMENT PROGRAM

Hypertention

Outcome criteria – Blood Pressure Control

Our nurse will:

Conduct Blood Pressure screening, Clinical Assessment, Patient Education, Diet, Weight Loss, Alcohol Intake, Exercise, Sodium Limitation, Stress Management & Anger Control, Medication Management & Outpatient Healthcare provider visits.

 

HEART FAILURE & CORONARY ARTERY DISEASE MANAGEMENT

Outcome Criteria – Prevent acute care admissions through care coordination and education.  Minimize the debilitating complications.

Our nurse will:

Provide timely discharge care coordination, health and environmental assessment, medication management, lifestyle behavior recommendations, weight control and CHF Zones for Management (green, yellow, red)

Company Profile

we are dedicated to the provision of comprehensive high-quality, client-and client family-centered home health care in the client’s place of residence.  Care is focused on the client’s unique physiological, safety, psychological, self-esteem, and self-actualization needs.

 

 

Locations

Glen Burnie:

216 N. Crain Highway, Suite 102

Glen Burnie, MD 21061

TeL: 410-424-2041

 

Salisbury MD:

1305 South Division St,Suite11

Salisbury,Maryland 21804

 

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