vnsny difficulty following prescribed medical plan of care, ... lung abscesses or pleural effusion...
TRANSCRIPT
V N S N YF U L L - S P E C T R U M P U L M O N O L O G YS O L U T I O N S
Filling in potential gaps in care
for patients across the pulmonary
disease continuum.
THE PULMONARY DISEASE CONTINUUM
COPD (CHRONIC BRONCHITIS / EMPHYSEMA)
The Newly Diagnosed COPD Patient
l Frequently presents with the following symptoms: o Dyspnea (shortness of breath), especially during physical activities o Wheezing or chest tightness o Chronic productive cough o Lack of energyl Often current or previous smokerl Some limitation of physical activity; may have difficulty leaving homel May be challenged by other comorbidities requiring physical therapy or skilled nursingl Treatment often begins with lifestyle changes such as better nutrition, regular exercise and cessation of smoking or substance abuse
COMMON GAPS IN CARE
The Acute COPD Patient
l Frequent respiratory infections or exacerbations l Recurrent ED visits or hospitalizationsl Home oxygen is common l Possible medication adherence challenges l Could be recuperating from acute illnessl May live alone, often homebound, with limited community supportl Difficulty with ADLs and IADLs, with no skilled nursing requirementsl Behavioral health conditions such as anxiety, depression or dementia
COMMON GAPS IN CARE
COMMON GAPS IN CARE
The Non-Adherent COPD Patient
l Difficulty following prescribed medical plan of care, and keeping physician follow-up visits l Often frail and elderly, homebound, with exacerbated condition or increased symptomsl Has functional limitations, socio-economic barriers, cognitive issues and gaps in self-management skillsl Often lacks caregiver supportl May have complex medication regimen, or challenges with correct use of oxygen, inhalers or DME l Could be experiencing complications from comorbiditiesl High risk for rehospitalization
The Complex COPD Patient
l Frequent progressive exacerbationsl Cyanosis (bluish discoloration of tongue, lips or fingernails) due to poor blood oxygenation in the lungsl Recurrent ED visits or hospitalizations l Home oxygen is commonl Condition complicated by multiple comorbidities and/or psychosocial issuesl May live alone, often homebound, with limited community supportl Behavioral health conditions such as anxiety, depression or dementia l Difficulty with ADLs and IADLs, with no skilled nursing requirementsl Palliative care needsl Possible candidate for sub-acute or nursing home facility
COMMON GAPS IN CARE
The Advanced COPD Patient
l Worsening dyspnea (shortness of breath), with minimal activity l Recurrent pulmonary infectionsl pO2 ≤ 55 mmHg (on RA) or oxygen saturation ≤ 88%l Supporting factors: o Cor pulmonale o Weight loss > 10% in past 6 months o Resting tachycardia > 100/minl High risk for rehospitalizationl Palliative Performance Scale (PPS) score < 70l Often bedbound, unable to work or perform most activities without assistancel Progressive dementia or cognitive deficits, weight loss, inability to maintain hydration or caloric intake
COMMON GAPS IN CARE
PULMONARY HYPERTENSION
l Patient condition is idiopathic, genetic or due to congenital heart disease, drug- or treatment-induced toxins or connective tissue diseasel Frequently presents with: o Dyspnea (shortness of breath) while exercising o Fatigue o Edema (swelling) of lower extremities o Palpitations or tachycardia l Some limitation of physical activity l May be challenged by other comorbidities requiring physical therapy or skilled nursingl Treatment often begins with lifestyle changes such as better nutrition, regular exercise and cessation of smoking or substance abuse
The Newly Diagnosed Pulmonary Hypertension Patient
COMMON GAPS IN CARE
The Acute Pulmonary Hypertension Patient
l Frequently presents with: o Dyspnea (shortness of breath) o Fatigue o Dizziness or syncope (fainting spells) o Chest pressure or pain o Edema (swelling) of lower extremities and ascites in abdomen o Tachycardia (cardiac arrhythmia with heart rate exceeding normal resting beats per min)l May live alone, often homebound, with limited community supportl Difficulty with ADLs and IADLs, with no skilled nursing requirementsl Behavioral health conditions such as anxiety, depression or dementia
COMMON GAPS IN CARE
The Non-Adherent Pulmonary Hypertension Patient
l Difficulty following prescribed medical plan of care, and keeping physician follow-up visits l Often frail and elderly, homebound, with exacerbated condition or increased symptomsl Has functional limitations, socio-economic barriers, cognitive issues and gaps in self-management skillsl Often lacks caregiver supportl May have complex medication regimen, or challenges with correct use of oxygen, inhalers or DME l Could be experiencing complications from comorbiditiesl High risk for rehospitalization
COMMON GAPS IN CARE
The Complex Pulmonary Hypertension Patient
l Chronic dyspnea (shortness of breath)l Uncontrolled hypertensionl Heart failure l Peripheral edema (swelling) of lower extremities and ascites in abdomen l Home oxygen is commonl Recurrent ED visits or hospitalizations l May live alone, often homebound, with limited community supportl Condition complicated by multiple comorbidities and/or psychosocial issuesl Behavioral health conditions such as anxiety, depression or dementia l Difficulty with ADLs and IADLs, with no skilled nursing requirementsl Palliative care needsl Possible candidate for sub-acute or nursing home facility
COMMON GAPS IN CARE
The Advanced Pulmonary Hypertension Patient
l Dyspnea (shortness of breath) at restl Cor pulmonalel pO2 ≤ 55 mmHg (on RA) or oxygen saturation ≤ 88%l Supporting factors: o Weight loss > 10% in past 6 months o Resting tachycardia > 100/min l Frequently has multiple comorbidities l High risk for rehospitalizationl Palliative Performance Scale (PPS) score < 70l Often bedbound, unable to work or perform most activities without assistancel Progressive dementia or cognitive deficits, weight loss, inability to maintain hydration or caloric intake
COMMON GAPS IN CARE
PNEUMONIA
The Newly Diagnosed Pneumonia Patient
l Frequently presents with: o Fever, sweating and shaking chills o Productive cough o Chest pain when breathing or coughing o Dyspnea (shortness of breath) o Fatigue o Nausea, vomiting or diarrheal Often current or previous smoker or excessive drinkerl Some limitation of physical activity; may have difficulty leaving homel May be challenged by other comorbidities requiring physical therapy or skilled nursingl Treatment often begins with lifestyle changes such as better nutrition, regular exercise and cessation of smoking or substance abuse
COMMON GAPS IN CARE
The Acute Pneumonia Patient
l Typically presents with symptoms of persistent fever, shaking chills, chronic productive cough, chest pain and difficulty breathing l Those most at risk: o Over 65 or under two years of age o Other co-morbidities such as COPD, heart disease, diabetes, kidney disease or malignancy o Weakened or suppressed immune systeml Could be recuperating from acute illnessl May live alone, often homebound, with limited community supportl Difficulty with ADLs and IADLs, with no skilled nursing requirementsl Behavioral health conditions such as anxiety, depression or dementia
COMMON GAPS IN CARE
The Non-Adherent Pneumonia Patient
l Difficulty following prescribed medical plan of care, and keeping physician follow-up visits l Often frail and elderly, homebound, with exacerbated condition or increased symptomsl Has functional limitations, socio-economic barriers, cognitive issues and gaps in self-management skillsl Often lacks caregiver supportl May have complex medication regimen, or challenges with correct use of oxygen, inhalers or DME l Could be experiencing complications from comorbiditiesl High risk for rehospitalization
COMMON GAPS IN CARE
The Complex Pneumonia Patient
l Typically presents with symptoms of frailty, loss of appetite, hemoptysis, muscle fatigue/aches and mood swingsl Those most at risk: o Limited capacity recuperating from acute illness, surgical procedure or hospitalization o Complications from other infections such as acquiring bacteremia, lung abscesses or pleural effusionl Recurrent ED visits or hospitalizations l May live alone, often homebound, with limited community supportl Condition complicated by multiple comorbidities and/or psychosocial issuesl Behavioral health conditions such as anxiety, depression or dementia l Difficulty with ADLs and IADLs, with no skilled nursing requirementsl Palliative care needsl Possible candidate for sub-acute or nursing home facility
COMMON GAPS IN CARE
The Advanced Pneumonia Patient
l Worsening dyspnea, with minimal activity l Resting tachycardia > 100/min l pO2 ≤ 55 mmHg (on RA) or oxygen saturation ≤ 88%l Supporting factors: o Cor pulmonale o Weight loss > 10% in past 6 monthsl Multiple comorbidities are commonl High risk for rehospitalizationl Palliative Performance Scale (PPS) score < 70l Often bedbound, unable to work or perform most activities without assistancel Progressive dementia or cognitive deficits, weight loss, inability to maintain hydration or caloric intake
COMMON GAPS IN CARE
VNSNY PULMONOLOGY SOLUTIONS
VNSNY Ambulatory Escort (Partners in Care private pay services)
Helps ensure safe transfer of patient to and from the hospital, same-day surgery, medical and dental appointments, and social events or other functions. l Assures physicians and family members that patient will arrive at appointments safely and on time
l Facilitates continuity of personal care and companionship support at home for short term or long term needs
l Available with as little as 24 hours notice
Customized services are available for patients who want home care not covered by insurance, paid for out of pocket or with long term care insurance.
VNSNY Behavioral Health and Dementia Management
Specialty care to improve clinical outcomes and patient satisfaction for psychiatrically and/or functionally homebound elderly patients with mood or cognitive disorders, including Alzheimer’s Disease. Using an interdisciplinary team, this innovative, person-centered approach allows Alzheimer’s patients to remain at home with the least restrictive level of care. The program includes: l Comprehensive assessment of mood and cognition, using evidenced-based screening tools l Individualized treatment plan, utilizing diagnosis-specific clinical pathways based on patient acuity l Medication management, with strategies to improve adherence l Diagnosis-specific psycho-education, using self-management tools with teach-back l Supportive counseling and goal-setting l Instruction in stress-reduction through coping skills, relaxation exercises, negative talk strategies, self-esteem building techniques and wellness l Care coordination and clinical monitoring of condition l Caregiver education for patients with dementia: o Disease process and symptoms o Caregiver techniques for ADLs and IADLs o Home safety, strength development and falls prevention o Promoting independence and positive behaviors o Managing difficult behaviors such as wandering, sun-downing, agitation and aggression l Identifying community linkages including support groups Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare and Medicaid. Medicare patients must meet homebound criteria.
VNSNY Complex Care Management
The management of populations most at risk for hospitalization with multiple chronic conditions has always been a core expertise at VNSNY. Defining elements of our program include:
l Reducing preventable rehospitalizations and avoidable ED visits
l Integration of physical and behavioral health interventions
l Care coordination from a Registered Nurse, a Social Worker or both
l Patient education and training in self-management
l Rehabilitation services (PT, OT, SLP) delivered across all settings
o Restorative or maintenance care
o Home safety programs
o Caregiver training for decreased burden of care
o Adaptive care planning
l Consultative outpatient and inpatient communication to PCP
l Facilitation of transfer to palliative care as needed
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria. Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.
VNSNY Complex Wound Care
Evidence-based, best-practice treatment of complex wounds, with educational training to engage the patient and the caregiver. Our highly skilled, certified Wound, Ostomy and Continence Nurses (WOCN) provide services and strategies designed to optimize healing and ostomy management. Working closely with the patient’s physician and home health care team, they customize a treatment plan and evaluate progress throughout the course of treatment. Services may include: l Topical wound care, prevention and management of infection
l Therapeutic interventions for slow-healing surgical wounds or chronic wounds such as pressure ulcers
l Self and caregiver training in how to change dressings, monitor healing, manage pain and recognize potential complications
l State-of-the-art therapies, such as negative pressure wound therapy (NPWT) technology to promote tissue growth and healing
l Support and education in self-care management for ostomy patients
l Digital photos of wounds may be emailed to WOCN specialists or physicians for consultation
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria. Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.
VNSNY Geriatric Care Management (Partners in Care private pay services)
l Coordination of everything from medical care to household assistance
l Accessing and leading a multidisciplinary team of clinicians, based on the patient’s specific needs
l Medication management and reconciliation
l Recommending home safety improvements and appropriate community resources (such as Meals on Wheels)
A comprehensive, fully customizable program providing expert geriatric advocates to help patients and their caregivers navigate long term care options to remain safely at home. Particularly beneficial for patients who live alone with limited community support. A registered nurse case manager will assess, coordinate, and manage a range of services including:
Customized services are available for patients who want home care not covered by insurance, paid for out of pocket or with long term care insurance.
VNSNY Haven Hospice Specialty Care Unit
The Haven provides round-the-clock care for patients with acute symptoms in a setting that promotes comfort, dignity and quality of life. The unit provides:
l Care by a dedicated, interdisciplinary team of professionals for acute symptom management until patients are stabilized and safe to return home
l Accepts patients with or without a DNR/DNI
l A place where family members are welcome at all times, with chair beds that allow family members to be with patients
l Access to a comfortable and welcoming family lounge for dining and relaxation
l A family conference area for consultations with the care team
Hospice care benefits are covered by Medicare, Medicaid and most private health insurance plans.
VNSNY Hospice and Palliative Care
Care that improves quality of life for patients and families living with advanced illnesses. Provided predominantly in the home setting, in long-term care nursing facilities and in the Goodman Brown Residence. Services include: l Care from an interdisciplinary team that may include a physician, nurse practitioner, nurse, social worker, spiritual care counselor and home health aide
l Treatment for control of pain and other symptoms, beginning with a Comfort Pack delivered to the patient’s home
l Cardiac Hospice Care program to address the special needs of advanced-stage Heart Failure patients
l Personal care at home
l Counseling and guidance on planning in the context of disease progression
l Emotional and practical support for patient and their families during an advancing illness
l Bereavement counseling after death of a loved one for as long as 13 months
Hospice care benefits are covered by Medicare, Medicaid and most private health insurance plans.
VNSNY Medical Social Work
l Identify community linkages (such as Meals on Wheels or senior day care centers)
l Help navigating the complexities of health insurance
l Assistance in applying for social and/or financial services
l Arrange for transportation or home improvement services
Licensed VNSNY social workers provide consultation, assessment and support for patients’ socio-economic, financial, cultural and emotional needs:
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria. Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.
VNSNY Medication Management
Our field clinicians work with patients, caregivers, and the community physicians to help manage any and all medications the individual takes in the home. Goal of making the patient or caregiver as independent as possible in their own medication administration. Services include: l Using electronic database, review all prescriptions (plus OTC and herbal medications) to identify potential interactions and notify patient’s physician
l Education focused on self-management and strategies that simplify regimes to improve adherence
l Instruct correct use and safety techniques of oxygen, inhalers, nebulizers or other respiratory equipment
l Adjustments to medications based on patient’s current clinical status, with ordering physician’s approval
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria. Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.
VNSNY PRI Assessment (Partners in Care private pay services)
A PRI assessment can determine:
l Medical condition/diagnosis
l Required medications and therapies
l Special diets
l Physical and mental abilities and limitations
l Ability to perform daily tasks
l Behaviors that may need management, such as aggressiveness, anxiety or depression
Required by law for individuals considering a move to a nursing facility. Our private-pay nurses are trained to assess whether a patient can function safely in the community or would be more appropriately cared for in a skilled nursing facility. Appointments available seven days a week, often within 24 hours of a request.
Customized services are available for patients who want home care not covered by insurance, paid for out of pocket or with long term care insurance.
VNSNY Palliative Care
l Educate patient and family on advance care planning
l Teach about illness and understanding choice of treatment options
l Treat pain and symptoms
l Design program to support maintenance of functional ADLs as appropriate
l Provide emotional support
l Connect families to community resources
A team approach to care focused on improving patients’ and families’ quality of life, and achieving personal goals for patients living with complex, progressive, life-threatening or life-limiting illness. VNSNY clinicians provide:
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria.
VNSNY Personal Care and Companionship (Partners in Care private pay services)
Patients are carefully matched with a highly trained, certified home health aide – or a team of aides – to provide assistance with activities of daily living. A registered nurse supervises the aide, oversees the care plan and updates it as necessary. Flexible scheduling is available, from hourly service through round-the-clock care, for short- or long-term, periodic or continuous care needs. Services include: l Reminders to take medications
l Recording vital signs
l Getting to and from medical and other appointments
l Food shopping, cooking and meal preparation
l Bathing, dressing and grooming
Customized services are available for patients who want home care not covered by insurance, paid for out of pocket or with long term care insurance.
VNSNY Population Health Management
l Engaging patients in their own health through education and coaching
l Providing longitudinal rather than episodic care to manage disease-specific interventions and necessary lifestyle changes
l Using EMRs and other technologies to promote more timely reporting and sharing of data
l Coordinating care between and across providers and settings
l Identifying community linkages
Promoting health as a means of reducing avoidable hospitalizations and preventing the development of new conditions or exacerbating existing conditions. Our nurse leaders, trained as certified Population Care Coordinators, focus on proactive, patient-centered, team-based care:
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria.
VNSNY Private Care Nursing (Partners in Care private pay services)
Registered nurses, who are experienced in disease-specific care and the care of medically complex patients, offer private duty nursing services not covered by most insurance. Helps reduce hospital length of stay, assist with safe transition across settings and minimize setbacks or potential risk of infection. Flexible, customized care can be arranged for short-term or ongoing needs, including: l Coordination of care and assistance in following doctors’ orders
l Pain management and medication reconciliation
l Supervision and clinical treatment for continuous care needs, such as:
o Ongoing infusion therapy o Wound, colostomy and ileostomy care o Tracheostomy care and tube feeding
o Catheter care
l Guidance for self-care and nutritional education
Customized services are available for patients who want home care not covered by insurance, paid for out of pocket or with long term care insurance.
VNSNY Pulmonary Rehabilitation Therapies (PT, OT, SLP)
Our physical and occupational therapists and speech-language pathologists strive to improve patients’ safety, strength and quality of life through evaluation, treatment and teaching. Based on the patient’s needs, they offer an interdisciplinary approach to hands-on care that is rooted in best practice protocols. l Assess ROM, strength, gait and need for assistive devices or mobility equipment
l Educate patients and caregivers on patient safety, assistive care methods and transfer skills
l Physical therapy to increase activity and improve balance, coordination and strength
o Teach breathing exercises and coughing techniques o Instruct in chest physical therapy, postural drainage and chest percussion o Teach energy conservation and relaxation techniques o Assess home environment for falls prevention
l Occupational therapy to increase range of motion, strength and endurance
o Retrain or modify personal care and other IADLs o Assess and instruct in proper positioning, body mechanics and DME as required
l Speech-language pathology to improve communication skills (speech, voice, receptive and expressive language, cognitive-communicative) and swallowing functions, if appropriate
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria (taxing effort, either physical or mental, in leaving home). Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.
VNSNY Skilled Nursing
Nursing care utilizing best practices based on established national (AHA/VNAA) guidelines to help achieve goal of maximizing patients’ physical, cognitive and behavioral gains to ensure a high level of independence at home, in the community and returning to work. Helps to reduce avoidable rehospitalizations and hospital length of stay, improve recovery and assist with safe transition across settings to minimize setbacks. l Coordination of care and guidance in adherence to doctors’ orders
l Instruct patient or caregiver in self-management of disease and need for medication adherence
l Conduct respiratory assessment including auscultation of breath sounds
l Demonstrate correct use and safety techniques of oxygen, inhalers, nebulizers or other respiratory equipment
l Evaluate home environmental or situational triggers and recommend strategies to eliminate them
l Assess and formulate action plan for changes in symptoms
l Identify strategies to assist complex medication management
l Linkages psychological support or smoking cessation assistance
l Instruct in nutrition and hydration measures
l Optimize preventative measures such as appropriate vaccines and proper hygiene
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria. Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.
VNSNY Telehealth
In-home telecommunications solutions to improve outcomes and reduce hospitalizations by tracking vital health information. Particularly beneficial for patients with chronic illnesses who take several medications or who require extra monitoring between physician or nursing visits. Physicians are notified promptly of any problematic shifts in vitals to help ensure patient stability. l Advanced nurse practitioner on call 24 hours/7 days a week
l Data is automatically transmitted to VNSNY Telehealth team and communicated to physician as needed
l Ensure patients are confident using and understand the results of equipment:
o Respiratory rate
o Pulse oximeter
o Blood pressure monitor
o Weight scale
o Glucometer
l Cellphone capability with no LAN required
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria.
VNSNY Transitional Care Program
In collaboration with provider partners across the continuum, VNSNY offers transitional care to help improve healthoutcomes, reduce avoidable rehospitalizations and improve the patient experience. Key principles include: l Best practices enhanced by VNSNY hands-on experience
l Plan for safe discharge to the home setting
l Use of proprietary risk stratification algorithm
l Emphasis on patient goal-setting, self-management and caregiver involvement
l Ongoing review for gaps in care or red flags
l Regular communication with community-based PCP, including confirmation of post-hospitalization follow-up appointment
Our clinical pathways are disease-specific, based on patient acuity and developed with evidence-based best practices. VNSNY accepts Medicare, Medicaid and most private insurers. Medicare patients must meet homebound criteria. Private care services are available for patients who want home care not covered by insurance, or to supplement or extend existing care.