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.

  • 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.
  • Congestive Heart Failure
  • Angina Pectoris
  • Hypertension
  • Cerebral Vascular Accident
  • Coronary Artery Disease              
  • Myocardial Infarction
  • Cardiac Dysrthymia
  • Heart Disease Unspecified
  • 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.
  • 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.

 
Home health agency teaching
 
Stage 1 Asyptomatic
 
Risk Factor Reduction
  1. Smoking Cessation
  2. Correct Obesity
  3. Treat Hyperlipidemia
  4. Treat Hypertension
  5. Exercise Program
 
Home health agency interventions
 
Stage 2 Symptomatic
 
Restriction of physical activity
Restriction of sodium intake
Pharmacotherapy generally used in combination:
 
  1. Diuretics
  2. Vasodilators
  3. Digoxin
 
Home health and doctor intervention
 
Stage 3 Refractory
 
Intravenous inotropic & vasodilator agents
 
  1. Dopamine
  2. Dobutamine
  3. Amrinone
  4. Nitroprusside
 
  • 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

For more information on our Cardiac Program call us at department at (248) 358-1196

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