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DISEASE MANAGEMENT PROGRAMS
Background: Studies have shown that patients with chronic conditions like diabetes, heart disease and other long-term illness account for almost 80% of health care expenditures in the United States. With the goal of improving health outcomes for these conditions while reducing costs, health care providers have developed disease management programs that combine patient care and education to foster greater compliance with treatment plans and to enable patients to better manage their own conditions.
OUR DISEASE MANAGEMENT PROGRAMS
THE MEDICAL TEAM has developed programs of disease management for two of the most prevalent diagnoses in its patient population, diabetes and heart/blood vessel conditions:
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Diabetes Self-Management Education Program
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Cardiac In-Home Care
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OTHER SPECIAL PROGRAMS
Our home health agencies also offer special programs that respond to the particular needs of patients requiring home care for wound management or after joint replacement surgery. Additionally, we have developed a program tailored to the needs of caregivers of persons with Alzheimer’s Disease.
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Wound Care Management
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Total Knee and Hip Joint Replacement Home Care Programs
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Behavioral Home Health Program
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Alzheimer’s In-Home Care
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DIABETES SELF-MANAGEMENT
EDUCATION PROGRAM
THE MEDICAL TEAM (TMT) has offered a comprehensive diabetes care and self-management education program for over ten years. The program, which was developed by a staff Certified Diabetes Educator, is based on the latest standards of the American Diabetes Association.
Components of the program include:
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Assessment of patient’s health status and educational needs.
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Development of an individualized care plan and educational goals.
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Skilled care as ordered by a physician and based on established protocols.
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Patient teaching based on proven educational protocols, tailored to individual needs and emphasizing the development of self-care management skills.
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Key features of the educational program include: glucose monitoring, medications, nutrition and meal planning, and prevention of complications.
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All teaching materials are easy to read and available in Spanish versions.
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Coordination and communication with the patient’s physician and all health care providers involved in the patient’s care.
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Outcomes reporting on key indicators of diabetes self-management and patient satisfaction.
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STAFF QUALIFICATIONS
Certified Diabetes Educators (CDE’s) oversee our diabetes self-management programs and provide training and teaching materials to our staff nurses. Registered Dietitians are also available to provide instruction about diet and nutrition. Many of our nurses have extensive experience in diabetes care and patient education, and many in our Texas agencies are bilingual.
CARDIAC IN-HOME CARE
THE MEDICAL TEAM offers a comprehensive in-home cardiac care and teaching program for patients to promote management of acute and chronic conditions such as coronary artery disease, congestive heart failure, myocardial infarction, and angina and management of risk factors for heart disease and stroke.
Our “Heart Smart” program includes:
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Assessment of patient’s health status and educational needs.
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Development of an individualized care plan and educational goals.
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Skilled care as ordered by physician and based on established protocols.
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Patient teaching based on an educational approach that progressively increases the patient’s understanding of heart disease and blood vessel conditions and the medications, diet, and lifestyle modifications that help to control them.
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Educational, easy-to-read “Heart Smart” patient manual.
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Emphasis on diet and its role in controlling cholesterol.
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Involvement of the patient’s family members in the learning process.
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Coordination and communication with the patient’s physician and all health care providers involved in the patient’s care.
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Outcomes reporting on key disease-specific indicators and patient satisfaction.
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STAFF QUALIFICATIONS
All of the nurses who care for cardiac patients receive special training to update their knowledge of heart disease and cardiovascular conditions, along with new treatment and monitoring techniques. Our home health aides also receive special training in the care and special needs of patients with heart or blood vessel conditions with emphasis on recommended diet and nutrition.
WOUND CARE MANAGEMENT
THE MEDICAL TEAM’s nursing staffs provide complicated wound care and management to patients who have non-healing wounds or ulcers, surgical incisions or wounds from traumatic injuries that have not completely healed, or new ostomies. Incontinence care and management techniques are also offered.
Services are provided in accordance with standards of care established by the Wound, Ostomy and Continence Nurses Society (WOCN) and include:
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Assessment of patient’s health status.
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Development of an individualized care plan.
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Skilled care as ordered by physician and based on established protocols.
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Instruction in skin and wound/ostomy/incontinence management and in the role of proper nutrition is given to the patient and caregivers.
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Coordination and communication with the patient’s physician and all health care providers involved in the patient’s care.
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Outcomes reporting on key indicators of wound improvement and management, and patient satisfaction.
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STAFF QUALIFICATIONS
Our wound management teams are comprised of nurses specially trained to provide complicated wound care. Many of our nurses are trained in the use of Wound Vacuum Assisted Closure (V.A.C®) devices, and several hold certifications in wound care and management.
(Note: Our offices in San Antonio, Texas; Reston, Virginia and Houma, Louisiana are certified KCI V.A.C.® providers.)
KCI web site
TOTAL JOINT REPLACEMENT
HOME CARE PROGRAM
THE MEDICAL TEAM’s Total Joint Replacement Home Care Program was developed to enable patients who have undergone knee or hip replacement surgery to regain as much flexion and extension of the operated joint as possible, achieve maximum functional independence, and ensure proper wound healing. Our goal is to help patients be even more active and live more fully than they were able to do before surgery. Our therapy protocols are based on established national standards.
Our Total Knee and Hip Replacement Home Care Programs include:
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Pre-operative in-home consultation (if requested by the physician)
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Assessment of health status and home environment.
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Development of an individualized care plan.
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Skilled care, including physical therapy, occupational therapy as appropriate and nursing care as needed.
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Patient and family caregiver education with emphasis on the recuperative process, the home environment and therapeutic exercises.
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A comprehensive patient manual with easy-to-read and useful information on all aspects of recovery in the home. Illustrations of commonly prescribed exercises are included.
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Coordination and communication with the patient’s physician and all health care providers involved in the patient’s care.
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Outcomes tracking of functional and objective results.
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STAFFING
Treatment team members include a physical therapist and a registered nurse. Additionally, case-specific treatment may include an occupational therapist and/or medical social worker. Home health aides are available when assistance with personal care and the activities of daily living are needed. Physician specialists, medical social workers and registered dietitians are consulted as appropriate. All care is provided in accordance with the orthopedist’s plan of treatment.
BEHAVIORAL HOME HEALTH PROGRAM
THE MEDICAL TEAM’s Journey Behavioral Home
Health Program was developed to assist patients and
families who are broken and wounded by mental
illness to journey towards wholeness. The Journey
program is based on established research outcomes
and meets all Medicare standards. Journey
provides specific services and support tailored to
the needs of individuals with severe mental
illnesses, including dementia.
Our Journey Behavioral Home Health Program
includes::
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Comprehensive assessment and
individualized care planning
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Medication management
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Interdisciplinary care management
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Community linkages
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Patient and family education
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Supportive services
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Telephone support
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Behavioral management
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Blood draws for serum levels of
specified psychiatric medications and
administration of decanoate medications
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STAFFING
All nurses working with Journey patients
are experiences psychiatric Registered Nurses who
meet Medicare's credentialiing criteria.
Our medical social workers are licensed to work in
home care and are trained in mental health. Our
aides receive training in dealing with the special
needs of Journey patients and families.
The Journey program is managed by a
Behavioral Health Coordinator, an experienced
psychiatric RN.
ALZHEIMER'S IN-HOME CARE
The agency’s In-Home Care Program for caregivers of persons with Alzheimer's Disease and related dementias includes:
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Assessment of patient's health, functional status and home environment.
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Development of an individualized care plan.
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Assistance with personal care and the activities of daily living (dressing, feeding, ambulation, etc.) provided by specially trained home health aides.
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Respite care to relieve family caregivers.
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Informative handbook for family caregivers on problems and coping strategies in caring for persons with Alzheimer’s.
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Coordination and communication with the patient’s physician and all health care providers involved in the patient’s care.
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Outcomes tracking of key measures of quality of life and caregiver satisfaction.
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STAFF QUALIFICATIONS
In addition to thorough orientation and ongoing home health aide training, the home health aides selected to provide care in this program receive 10 hours of intensive training focusing on the psychosocial and behavioral aspects of Alzheimer's disease.
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©2006,
THE MEDICAL TEAM, INC. |
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