Goal #1: Decreasing Hospitalization sess’ and Emergent Care Needs

29% of all Home Health admissions result in re-admission to hospital Most of those are within the first 2 weeks of Home Health service Beulah Home Health implements specialty programs with specific interventions to decrease this number Front-load Skilled Visits Beulah Home Health front-loads skilled visits to ALL patients admitted to:
The Cardiac Program
The Palliative Care “Bridge” Program
The Diabetic Program
Orthopedic Program
the idea is to catch symptoms early enough to intervene at home, thus eliminating the need for emergent or hospital care

Plan of Care Interventions: Palliative

Psych/Social eval
PT/OT referral if pt requires assist with ADL’s
HHA for assist with ADL’s
Continuum of staff for hospice transition
Focus on symptom management
Close physician contact

Plan of Care Interventions: Cardiac

We make sure every patient has a scale that they are ABLE to use.
Dietary eval/education
We begin instruction on admission of:
. Monitoring daily weights
. Monitoring nutritional intake/sodium intake
. Cardiac medications Compliance
. PT/INR tracking. Fingerstick testing available for those on warfarin
. Education on when to access/ call home health as opposed to calling 911
We complete a Risk Assessment for Emergent Care on admission
We follow up within 24 hours to assess for complications, provide further teaching and complete the individual Plan of Care based on those findings

Plan of Care Interventions: Orthopedic

Physical therapy evaluation
Occupational therapy evaluation as needed
PT/INR tracking. Fingerstick testing available
We begin instruction on admission of:
. Signs and symptoms of infection
. Pain medications need
We complete a Risk Assessment for Emergent Care on admission
We follow up within 24 hours to assess for complications, provide further teaching and complete the individual Plan of Care based on those findings

Plan of Care Interventions: Diabetic Care

We make sure every patient has a Glucometer that they are able to use.
We work with their primary care physician and insurance company
Dietary eval/education
We begin instruction on admission of:
. Performing fingerstick blood glucose tests
. Monitoring nutritional intake
. Diabetic medications and compliance
We complete a Risk Assessment for Emergent Care on admission
We follow up within 24 hours to assess for complications, provide further teaching and complete the individual Plan of Care based on those findings

Goal #2: Decrease distressing symptoms

Assess and ACT:

Pain assessment
. We never leave a patient reporting over 5/10 without a call to physician.
. We follow up within 24 hours any time regime changed
Dyspnea assessment
. We use 0-10 scale,
. OT/PT consult for energy conservation
. 02 evals and orders
Assess for s/s wound infection every visit
Assess daily weights for changes every visit

Goal #3: Improve Quality of Life indicators

Patients answer questions related to Quality-of-Life on admission and at intervals throughout their episode.
Evidence of depression, financial or spiritual distress result to call to their physician, and a recommendation to consult whomever their Spiritual Counseling is if any.
Sometimes physical symptoms are often difficult to control in the presence of other distress.
Sometimes a holistic approach increases efficacy in managing physical manifestations, such as pain, dyspnea and anxiety.

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