The UPMC/Jefferson Regional Home Health Disease State Management Program manages patients with chronic illness in their own residence, while increasing compliance, reducing costly readmissions to the hospital, and reducing Emergency Department visits. High-risk, high-volume diagnoses have been identified and disease-specific programs developed. Outcomes are measured using predetermined criteria such as readmission to the hospital in less than 30 days, number of visits to the Emergency Department, compliance with medications, and dietary restrictions.
Healthy Hearts at Home is a program for patients primarily diagnosed with heart failure but also can be for patients with conditions such as coronary artery disease, hypertension, myocardial infarction, and COPD. Specialized nurses are able to closely monitor these patients and report significant changes to the attending physician to provide the appropriate interventions in the home.
Telemonitoring has also been a successful way to provide closer supervision and support.
Ed U-Turn™ is an integral part of the cardiopulmonary program. We provide follow-up visits for patients evaluated in the Emergency Department within a predetermined period of time to prevent rehospitalization.
High-tech services provided through the cardiopulmonary program include, but are not limited to, ventricular assist devices, PleurX catheters, nocturnal pulse Oximetry, services for patients on IV inotropics, and care of patients with tracheotomy that may or may not be vent dependent.
UPMC/Jefferson Regional Home Health's Diabetic Disease State Management Program was been developed to manage patients with this chronic disease in their own home. With adequate education, medication management, and multi-disciplinary care, patients with diabetes can be provided with appropriate and timely interventions to avoid preventable complications and hospitalizations.
