– Proactive Disease Management Education program with emphasis on disease processes, symptom management and behavior modifications: ie. low sodium diet, exercise and weight management.
– Full nursing assessment of the patient and the home environment.
-CHF Weight Guidelines carefully reviewed and documented with the patient and their caregivers.
-Front loading visits
-Telehealth- All CHF/COPD patients participate in our telehealth program which focuses on physical status (such as weight, edema status, oxygen use, etc.) self management behvior modification and teaching (ie. occupational therapy- energy conservation).
-Telemonitors are incorporated into our Plan of Care for High Risk Patients.
-Emergency Care Plans are reviewed with the patient and their families.
-Emphasize the importance of communication with the patient as well as the physician, pharmacist and caregivers.