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)
