orders of the referring physician.
These services are available based on the orders of the referring physician.
SKILLED NURSING (SN):
Assessment of general health history and body systems; education on management of disease processes & medication, home safety, pain control, infection prevention; wound care, IV therapy, ostomy care and other modalities ordered by the physician.
REGISTERED DIETITIAN (RD):
Develops interventions to assist patients in achieving dietary requirements imposed by various health conditions (i.e., wounds, diabetes, etc).
PHYSICAL THERAPY (PT):
Assessment of physical functioning, exercises to promote increased balance endurance, more stable walking pattern, muscle strength, joint movement, pain control, and fall prevention.
HOME HEALTH AIDE (HHA):
Assists patients with bathing safely while they are recouperating and receiving skilled services (SN, PT, OT, SLP) to improve endurance and function.
OCCUPATIONAL THERAPY (OT):
Assists patients in becoming more independent in functional activities of daily living, such as bathing, dressing, grooming, and meal preparation.
COORDINATION OF MEDICAL EQUIPMENT AND SUPPLIES:
Our office staff will coordinate home delivery of equipment and supplies ordered by physician.
SPEECH-LANGUAGE PATHOLOGY (SLP):
Develops strategies to help patients overcome communication deficits related to neuromuscular conditions and interventions to address swallowing deficits.
PHARMACY:
We are able to coordinate home delivery of medications for clients requesting this service.
MEDICAL SOCIAL WORKER (MSW):
Assists patients in obtaining community resources such as meals-on-wheels, chore provides, transportation, alternate housing, financial services, patient advocate, etc.
PHYSICIAN:
Office and Clinical staff coordinate your care with the Physician over-seeing your care (primary care or specialty). If you are unable to leave home for any reason, we will coordinate with your physician to provide a home care physician (one who makes house calls) to handle your care until you are able to resume office visit.
Specialized Services
1. Fall Prevention
Each year, falls of people 65 and older account for a significant number of Emergency Room visits, hospitalization, nursing home placements, and death. Our goal is to facilitate prevention of falls via a multi-disciplinary approach, thereby reducing the potential for ER visits, hospitalizations, nursing home placements, and death in our clients.
- Skilled Nursing: Our Nurse performs an assessment of fall risk, including but not limited to: client’s physical and psycho-social status, medications, environmental obstacles.
- Physical Therapy: Our Physical Therapist performs an evaluation of strength and mobility.
- Occupational Therapy: The Occupational Therapist performs an evaluation of client’s ability to complete ADLs (bathing, dressing, grooming, etc.).
- Medical Social Worker: The MSW evaluates our client’s need of community resources and assists with referrals to those agencies.
Based on the evaluations, a plan of care is developed and reviewed with the client’s physician. The team then begins working with the client/caregiver on measures to reduce actual risk factors and teach them how to identify potential future risk factors.
Immediate response to a fall is available to clients enrolled in a medical alert system.
2. Wound Care
Our Wound Care Certified (WCC) nurse will assist in evaluating wounds and collaborate with physicians to determine the best course of treatment. For wounds that are more challenging, a Wound Care Specialist will be consulted. A Registered Dietitian is also available to address the specific nutritional requirements to facilitate wound healing.
3. Diabetes Management
The best way to prevent complications of Diabetes Mellitus (nerve/kidney/circulation/vision damage) is to keep blood sugars under control. Our nurses will develop a plan of care with the physician to assist clients in attaining this goal. The primary component of this plan is education.
Clients are educated on:
- Medications, including insulin administration
- Monitoring blood sugar levels
- Signs & symptoms of high & low blood sugar levels
- Prevention & treatment of high & low blood sugar
- Diet
- Complications of Diabetes Mellitus
- Diabetic precautions
- Foot exam/care
- Any other specific needs of the client related to Diabetes Mellitus
A Registered Dietitian is available for consult with clients who have particularly challenging nutritional issues. At the completion of this program, the client (or caregiver) should be able to demonstrate knowledge of management of Diabetes Mellitus.
Hospital Reduction Program
Hospitalization is a major factor in over-all decline in the geriatric population due to immobility, loss of control, severely limited social contacts and increased exposure to infection, to name a few. Just think about the effects of being in bed with the flu for 2-3 days. Even a younger person may have weaker muscles, become light-headed after being upright for a few hours. These results can be devastating for an older person.
One of our goals is to keep clients from being admitted to the hospital. Granted, there are instances in which hospitalization is the only viable option, however, those should be minimal.
One of the primary reasons for hospitalization is exacerbation (worsening of symptoms) of a chronic disease process. This occurs when a person does not have the knowledge to take medications as prescribed and manage symptoms of a chronic illness. The Homecare Nurse teaches clients about medication and disease processes so they are able to manage symptoms better, contact physician with subtle changes and obtain treatment at home before the condition requires hospitalization.
Joint Rehab
There are studies indicating that people rehab quicker at home rather than in-patient rehab centers after joint surgery. One of the reasons is that there is no anxiety as to “when” or “if” they will go home – they are already there! Another reason is that they are more comfortable at home so are in more control of the situation. Rehab is specific to the client’s home environment, i.e. getting in & out of a stall shower vs. tub shower. The goal of home rehab is to achieve strength and mobility that will allow graduation to outpatient rehab. Our Rehab Specialists work with the client, surgeon, primary care physician, and family to achieve this goal.
