Our team of licensed practical nurses, registered nurses, and pharmacists collaborate with the patient’s primary care providers, specialists, and insurer to meet the health and wellness needs of patients with Diabetes, Heart Failure, and Chronic Obstructive Pulmonary Disease. Nurses initiate telephonic outreach calls to patients at home and review the 60-day program. Within the two-month period, patients receive a minimum of four telephonic or video conferencing sessions lasting an average of 20 minutes. Included in sessions with each patient is educated on the disease process, a review of the prescribed, individualized plan of care, discussion of evidence-based approaches to preventive care strategies and management, as well as reinforcement and coordination of follow-up services. Risk factors are highlighted, in addition to, signs and symptoms, identifying triggers to avoid, and crisis management. Referrals are made to community health workers, social workers, or outside agencies as requested by the patient, as part of our standard care coordination services, toward meeting health and wellness goals. The chronic disease management program has shown to further reducing the risk of future hospitalizations.
