| Patients admitted to Health Care Partners with
a diagnosis of chronic congestive heart failure or acute coronary
artery disease will be cared for by our Cardiac team which consists of
registered nurses, physical therapists, registered dieticians, and
certified home health aides. The team works together to maximize
positive outcomes through education in the management of the disease
process, nutritional screening, cardiac enhancing exercises,
medication management and assessing psychosocial needs. |
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- Minimize cardiac disease exacerbations which, in effect
reduce emergency room visits and hospitalization.
- Ensure safety and availability of professional support to
patients and caregivers.
- Render positive outcomes via a holistic interdisciplinary
approach in the management of the disease process.
- Provide instructions related to medications, nutrition and
exercise.
- Facilitate compliance with physician follow up-visits.
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- Congestive Heart Failure
- Angina Pectoris
- Hypertension
- Cerebral Vascular Accident
- Coronary Artery Disease
- Myocardial Infarction
- Cardiac Dysrthymia
- Heart Disease Unspecified
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- Registered Nurse -
To case manage all disciplines, educate the patient
and caregiver, follow guidelines established by
individualized physicians and establish mutual goal
setting to prevent recurrence of emergency room visits and
hospitalization.
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Physical/Occupational Therapist - To develop
individualized exercise programs for patients, improve
endurance, activity levels and safety through established
and recognized practices and guidelines developed by
physicians and therapists for home maintenance.
- Medical Social
Worker - To address the psychological and
social issues related to the disease process,
noncompliance problems, medication costs, sexuality, death
and dying and resourcing multiple needs of the home care
patient.
- Registered
Dietician - To assess, educate and provide
resource material and direction to the home care patient
experiencing cardiac problems in relationship to realistic
individualized meal planning in accordance with the
physician's orders.
- Certified Home
Health Aide - To provide personal care services
to the cardiac home care patient who is unable to provide
for his / her own safety.
- Spiritual Care -
To provide spiritual counseling for patient's
families and caregivers experiencing grief or the loss of
an individual.

Through patient education, all multidisciplinary team
members work together towards the vision of "Self Directed"
learning, with patients taking a more active role in their
own well-being. Our patient teaching program focuses
on the steps the patient needs to know to become an active
participant in managing their disease states or condition,
understanding their therapy regime, and ultimately,
motivating them to take responsibility for establishing and
maintaining their cardiovascular fitness.
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Home health agency
teaching |
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Stage 1 Asyptomatic |
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Risk Factor Reduction |
- Smoking Cessation
- Correct Obesity
- Treat Hyperlipidemia
- Treat Hypertension
- Exercise Program
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Home health agency
interventions |
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Stage
2 Symptomatic |
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Restriction of
physical activity |
Restriction of sodium intake |
Pharmacotherapy generally used in combination: |
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- Diuretics
- Vasodilators
- Digoxin
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Home health
and doctor
intervention |
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Stage
3 Refractory |
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Intravenous
inotropic & vasodilator agents |
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- Dopamine
- Dobutamine
- Amrinone
- Nitroprusside
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- Care of the patient according to AHCPR guidelines
- Intravenous Therapy in the home
- PIC Certified nurse
- Physician home visits
- Collaborative working relationship between hospital,
clinic, and homecare

- Monitor and manage CHF and CAD patients in the home
- Collect and manage CHF research information
- Reduce costs of managing CHF patients
- Reduce hospital re-admissions
- Reduce hospital emergency room visits

The cardiac team works together to maximize positive
outcomes through...
- Patient education
- Management of disease
- Nutritional screening
- Cardiac enhancing exercise
- Medication management
- Assessment of psychological needs
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For more
information on our Cardiac Program call us at department at (248)
358-1196 |
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