Chronic Disease Management

Managing co-morbidities in the chronically ill

Coordination of care is especially crucial for patients with multiple chronic diseases, as treatment for one condition may conflict with another condition.  To prevent complications, our skilled nurses work with you, the patient’s physician, on a long-term plan of care that takes into consideration the patient’s complete medical profile. We coordinate care with other members of our homecare team, including therapists and social workers, to ensure appropriate use of medications and adherence to other treatment regimens. 

We educate patients about their chronic conditions, teaching them and their families how to recognize early signs and symptoms of illness that may require medical attention.  Our TeleHealth remote monitoring program may be recommended to help the nurse, physician and patient keep track of any changes in vital signs that may require a new course of treatment. We also provide instruction on medication management, and on nutrition and lifestyle changes that can reduce risk factors and aid patient well-being.

We will help you keep your patients out of the hospital, and keep them living safely and comfortably at home.

Program services:

• Hands-on care and management of patients with cardiovascular diseases, diabetes, arthritis, mental health issues and other chronic conditions
• Developing and assisting with long-term patient care plans
• Medication reconciliation and education
• Daily TeleHealth remote monitoring of patients’ vital signs
• Patient education programs for medication management, nutrition, symptom recognition and other health-related self management skills

For more information on our Chronic Disease Management Services please call 914-682-1840.