Cardiac Disease Management
- Patients are seen within 24 hours of discharge from hospital except when patients otherwise make other arrangements (ie physician visits, patient preference, etc.)
- Prevent re-hospitalization through patient health coaching
- Cardiac patients will be monitored for their oxygen saturations (whether on room air or on O2), taught on prevention of edema, assessment of jugular vein distention and dyspnea, monitoring of HR and BP thru logs
- Registered Dietician available for individualized establishment of cardiac diet.
- 24 hour/7 days a week, available on-call RN for triage and support, questions or concerns, PHYSICIAN coordination as needed
- Services available: Registered Nurses, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Worker, Registered Dietician, and Certified Home Health Aides
At Each Visit
- RNs will perform a head to toe assessment with emphasis on cardiac status, edema, presence of chest pain or SOB, and abnormal vs normal weight gain. Changes in condition will be reported to the physician for effective management and help prevent hospitalization.
- Nurses on the case will perform a cardiopulmonary assessment, vital signs, and any other ordered care such as labs, wound care. Any abnormal findings will be communicated to the physician so that the nurse can effectively aid in its management.
- Medications will be checked for proper dose, route, frequency, side effects, and knowledge of action.
- The plan of care includes: disease process education, safety measures, fall precautions, emergency plan and management of patient’s overall condition which may include social work, dietary consultation, and certified nursing assistant.
Hospital Case Management, 2010 February; 18(2):22,27.
The Medicare Payment Advisory Commission (MedPAC) has advised congress that of the 30% re-hospitalizations, 76% of these readmissions may be preventable. Through the use of Victory Home Care Services, we can all work together as a team to reduce re-hospitalizations (Eva Ward, RN Administrator, Victory Home Care)
For referrals or questions please feel free to contact (480) 726-6553 or fax (480) 726-3329.