Patient Care Solutions’ disease management program aims to help patients with various conditions live safely in their own homes. We focus on managing specific conditions using a variety of tools including medication, teaching, vital signs monitoring, and enlisting caregiver support. Certain conditions require strict adherence to certain medications, diet, or other regimens. Getting the patient to understand and buy into these regimens is one of our goals. When our goals become the patient’s goals, compliance becomes a lot easier.

Who can Benefit from Disease Management Program?

Anyone with a poorly managed disease is a good candidate for this program. This includes:

  • Patients with diabetes or have complications related to diabetes
  • Patients newly diagnosed with chronic diseases such as diabetes
  • Patients who take a lot of meds to manage specific conditions
  • Patients who live alone or have unreliable caregivers
  • Patients who have a history of or are at risk of falling
  • Patients with certain disabilities that make it difficult to comply with their doctors’ orders

Disease Management Process

Referral: Patients are referred to our agency by their PCP or a caregiver. In the latter case, we contact the primary care physician to authorize the treatment.

Comprehensive Assessment: Once enrolled, we establish a baseline by doing a thorough head-to-toe assessment of the patient. The comprehensive assessment includes:

  • Patient’s current medical condition
  • Documentation of current medications
  • The ability of the patient to perform ADLs and IADLs
  • Patient’s living conditions and their safety

Reconciliation: Following the assessment, we confer with the PCP to reconcile our findings with theirs. We especially check the medications to ensure what the patient is taking matches the PCP’s list. We also check current conditions to make sure the PCP is aware of any undiagnosed or unreported condition.

Care Planning: We discuss the patient’s condition with the doctor and agree on a specific care plan. The plan is largely driven by the results of the assessment. Each plan is for a specific period—usually 60 days. The plan is focused on achieving measurable goals within this period. The plan calls for a specific number of visits during this period by one or more of our disciplines—nurse, therapist, social worker, or home health aide.

Implement Care Plan: During each visit, our clinicians follow the care plan created for this patient. The care plan may involve:

  • Medication administration
  • Teaching on various topics including diet and medications
  • Assessment of body systems
  • Assistance with ADLs such as bathing or changing clothes
  • Helping patients learn how to use cane, walker, or other medical equipment

These findings are reviewed by our case managers and if necessary the PCP is notified. The PCP may order changes to medications or alter the care plan.

Re-Assessment: After 60 days, we do another assessment to gauge how well the goals we met, and if another period of 60 days is necessary.

Getting Involved

If you are a PCP and have patients you think can benefit from this program, please contact us. Our clinical manager can discuss the details of the program with you and your team and help identify candidates. If you are a caregiver and you think a loved one can benefit from our disease management program, please contact us. We will contact their doctor to notify them about your interest. This program is covered by most insurance plans including Medicare and Medicaid. There is no co-pay or any out-of-pocket cost to you or your family.