Case 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 and home health support.
• Patients with certain diagnoses such as CHF and COPD have programs geared towards preventing
  re-hospitalization
• 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
• Case Management is filtered through RN Supervisors in the office to ensure that a physician can always contact a and coordinate with an RN.
• Community Liaison available to meet with and discuss home health with patients and help facilitate transition and discharge from hospital. This includes work up, follow ups as necessary, and coordination with office.

At Each Visit

• Nurses on the case will perform a head to toe assessment with emphasis on specific diagnoses related to each patient, cardiopulmonary assessment, vital signs, weights, and any other ordered care such as labs, wound care, infusion, etc. 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, frequency, route, 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.

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.