CARDIAC DISEASE MANAGEMENT SERVICE

 

• Provides an advanced level of quality, skilled care and cardiovascular disease management services within a client’s home as an adjunct to ongoing physician care.

• Multidisciplinary efforts focus on improving the quality and cost-effectiveness of care for select clients with chronic illness.

• Utilizes an individualized, step-by-step approach; clients with cardiac disease learn how to proactively self-manage their illness with confidence while remaining in the comfort of their own homes.

• Provides physicians with the security that the client's requiring cardiac disease management services will receive appropriate care at home.

• Clients learn to recognize the signs and symptoms of heart failure and proactively gain a measure of control over their health and well-being.

 

Goals/Objectives

• The primary goal of CDMS is the self-management of care.

• Early recognition and intervention of symptoms thereby reducing the number of hospital re-admissions and unnecessary emergent care.

• Improved client compliance with medications and diet regimen.

• Increased functional abilities, and overall enhanced quality of life.

• Through education and assessment, client anxiety is reduced and confidence is gained in the day-to-day management of their disease.

 

Specifics

• A medical order is necessary to initiate the plan of care. The CDMS commences with six educationally structured home visits, made by VNA of LI RNs, after a client is released from a hospital. Within 24 hours of the referral, the client is assessed in their home and the road to independence (involving education, self-awareness and self-management) begins.

• CDMS utilizes a variety of interactive educational tools including a client-centered colorful, easily understood booklet; a color-coded symptom self-management grid and an educational DVD that details signs and symptoms of the disease. This educational process plays a pivotal role in empowering clients completely to manage their medications properly and to understand their symptoms completely.

• Focuses on having clients take an active role in the self-management of their chronic disease by managing medications and diet within their day-to-day life style.

• Uses the application of Telehealth Monitoring technology, which enables clients to self-monitor their cardiac disease.