Nearly 1 in 5 people with pneumonia incur costly, stressful return trips to the hospital within the first 30days of being diagnosed with the condition. Individuals with pneumonia also are at a higher risk of having additional, underlying conditions that can make it more difficult to get better without assistance. Research shows that many of these rehospitalizations are potentially preventable through the use of proactive, team-based care coordination programs.
Our @HomeCore Solutions ™ Disease Management Clinical Pathways program is designed to provide positive outcomes and our clinical teams are equipped with the expertise and passion for working with patients, families, and physicians for reducing the likelihood of hospital readmissions for individuals with pneumonia. The Pathways uses clinically proven methods to educate people with pneumonia and their families on the key aspects of the condition and how to monitor symptoms, adhere to a plan of care, take their medication, improve wellness, and stay healthy.The programs are designed to provide positive outcomes and our clinical teams are equipped with the expertise and passion for working with patients, families, and physicians for reducing the likelihood of hospital readmissions for individuals with pneumonia.
Our Clinical team is specially trained, to ensure:
• Patient clearly understands the plan of care from the physician and takes the necessary steps needed to get better
• Family feels confident their loved one can self-manage their condition
• Physician is kept up to date on the patient’s condition and made aware of any circumstances that may require attention
The primary focus is to improve the wellness of individuals with pneumonia to make sure they take their antibiotics and that early signs of decline are addressed promptly. The Assure’s Clinical team actively engages with a patient with pneumonia through regular in-home visits and phone calls to make sure the individual takes their medicine and understands why it’s so important to do so. Assures Clinical team members are specially trained to look for and communicate key changes in symptoms to stay ahead of any potentially dangerous changes in an individual’s condition.
What happens during an Assure Home HealthCare @HomeCore Solutions™ Pneumonia visit?
• Listen to the client’s and family’s concerns
• Understand their antibiotic regimen, and gauge how well the individual and their family are coping with the diagnosis, and understand
• Nursing Assessment: Perform a focused physical assessment with attention to respiratory system and oxygenation
• Go over: Physician orders, medications, appointment date and things to bring, and Plan of Care with Client and Family
• Education: Provides a comprehensive educational overview on the disease process (Teach Back Mythology)
Assure Care Team RN’s, CNAs, and HHAs
• Check: Client’s vital signs/pulse oximetry, home safety, and food, medication, and equipment supplies
• Assist: Daily living activities, use of incentive spirometer if ordered
• Review and Reassure: Plan for the day, maintain a helping attitude, remind the individual to use pursed lip breathing
• Completes required paperwork, call the Physician, RN Clinical Pathways Coordinator with update and ask if they’ve met all needs
Exclusive @HomeCore Solutions™ Zine Management Resource for Pneumonia patients and their families
•Patient Education Booklet – Think of this as the story of the condition that the individual, caregiver, physician, and family can reference to track progress. The client and family education material – Informative, illustrated packet provides useful information on how to stay healthy.
• Symptom alert – Easy-to-read reference card helps monitor symptoms:
• Green = I am doing well
• Yellow = I should notify Assure Case Manager ( CALL ME FIRST )
• Red = Time to call 911
Additional Assure @HomeCore Solutions™ Disease Management 23 Diagnosis including:
• Heart Failure, Heart Attack / Acute Myocardial Infarction (AMI)