Re-Hospitalization Prevention

 

Our Proactive Disease Management Education program teaches our residents about disease processes, symptom management and behavior modifications.

 

• Full nursing assessment of the patient and the home environment.

• CHF Weight Guidelines are carefully reviewed and documented with the patient and caregivers.

• We focus on physical status (such as weight, edema status, oxygen use, etc.), self management behavior modification, and teaching (ie. occupational therapy, energy conservation).

• Telemonitors are incorporated into our plan for High Risk Patients.

• Emergency Care Plans are reviewed with the patient.

• We emphasize the importance of communication between the resident and the physician, pharmacist, and caregivers.​