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)