Specialty Program

Congestive Heart Failure Program

For patients dealing with congestive heart failure, our team conducts comprehensive cardiopulmonary assessments with each visit. We also are ordering specific biometric monitoring for edema management, weight, respirations and blood pressure above and beyond our standard checks. We utilize therapy services to improve function, and we take steps to educate patients and their families on disease management. In all steps, patients and their families play a collaborative role in care plan development, which is essential to setting helpful and healthful patient behaviors and comfort.

Specialty Program

Wound Care Management Program

Management of patients in our wound care management program begins with specially-trained wound, ostomy and continence nurses evaluating and making recommendations around treatment modifications. Our team uses evidence-based, advanced wound care products and conducts comprehensive weekly assessment visits. We collaborate with specialists that are billed under Medicare Plan B. Our approach shows dramatic outcomes differences, well above state and national averages.

Specialty Program

Medication Management Program

For patients and families who are organizing complex medication regimens, our team immediately engages a comprehensive assessment and reconciliation. We work to evaluate patient medication for drug-to-drug interactions and duplication across the pharmaceutical regimen. We’ll take the lead and collaborate with the ordering physician and pharmacy to resolve any issues, and we’ll take the time to educate patients and their families on management of drug regimens. Our collaborative and proactive approach gains traction, with physicians on average responding more quickly than average to successfully address issues.

Specialty Program

Fall Risk Prevention Program

Our team works proactively to keep our patients healthy in their homes through a hands-on fall prevention program. We identify patients with potential mobility issues or recovery challenges, and conduct comprehensive fall risk assessment of the home environment. In addition to recommending changes, we’ll provide the patient and families with education around smart habits and movements that mitigate fall risk. We also immediately introduce therapy services and front load the frequency of services that will empower patients to move more comfortably in their recovery. Our patients have a three to four times significantly lower percentage of falls with a major injury than state and national averages.

Specialty Program

Readmission Management Program

Across our patient population, we work to reduce unnecessary readmissions back into hospitals. Within 24 hours, our team has conducted comprehensive risk assessments, and begun to engage patients on a plan of care. Our protocols emphasize timely communication with primary care physicians after hospital discharge, as well as referrals for any needed medical follow ups. We take the time to educate patients, families and caregiving team on managing their illness or identifying important symptoms of complications so they address any issues quickly. These sensible steps and smart processes have helped our patients get the right care, quickly, often in the home, and avoid escalations that drive readmission at rates, all at distinctly better than national and state averages.

Specialty Program

Surgery & Joint Replacement Program

Attentive rehabilitation after surgery in the home provides patients with clear steps back to function, comfort and health. It also minimizes the risk of injury or incomplete return to function that could have long-term effects. Upon patient return home, our team will conduct next day therapy evaluations to confirm patient goals and needs. Our team also conducts full home environment assessments and identifies the appropriate supportive services that necessary for the rehab period. We’re in direct communication with orthopedic surgeons, who see our team as an extension of their treatment. And we’re reviewing treatment and rehabilitation plans with patients and their families to minimize discomfort and maximize progress.

Specialty Program

Neuro-Cognitive Management