OneCare: Chronic Heart Failure

In-home integrated care for Chronic Heart Failure

OneCare CHF Timeline

The Five Star Home Health Care nurse and Heal physician or nurse practitioner will meet the patient, family, hospitalist and discharge nurse in the hospital prior to discharge. The goal is to develop the OneCare plan, document medications, discuss who is going to administer medications and review discharge instructions for a safe and coordinated discharge home.

In-person discussion is necessary to improve communication, document all details and ensure that care, equipment and resources are integrated for a successful transition home.

The first 2 weeks home incur the highest risk for problems causing discomfort and potential re-admission. During the patient’s transition back to independence, they will receive in-home visits from a Heal physician or nurse practitioner, nursing visits, therapy and personal care.

Changes in weight, heart rate and blood pressure are important for CHF recovery and will be monitored via the Heal Hub remote patient monitoring service. The home health aide will ensure meal restrictions are followed, fluid intake meets requirements and provide medication reminders.

The patient’s progress and issues impeding recovery will be regularly communicated with the Primary Care Physician.

The nurse will follow physician instructions on teaching the patient and family self-management of CHF symptoms and other chronic diseases that may be present.

Home health services will be utilized to ensure a stable path to independence with appropriate nursing and personal care support for activities of daily living. The patient will be observed for symptoms of depression or anxiety and for medication refills. A cardiac rehab therapy and home exercise plan will be implemented.

Heal Hub will remain in place to monitor vital signs and to be an ongoing connection to medical professionals.