Complete Care: A Comprehensive Home Health Solution
Profile
Service: Home Health
Diagnosis: Spinal Stenosis, Atrial Fibrillation (A-fib), Diabetes, and Hypertension
Description
The patient—a 72-year-old who previously received a thoracic spinal fusion—underwent revision surgery due to increased pain. The patient was sent home to rehabilitate under Constellation’s home health care services. Constellation leveraged nurse practitioner (NP) oversight and telemonitoring to help the patient recover safely at home and prevent further hospitalization.
Complete Care Approach
To significantly increase clinical oversight after revision surgery, the care team installed a telemonitor, which alerted them to multiple blood pressure (BP) readings. A follow-up call revealed that the patient was feeling dizzy and taking additional BP readings. This information triggered a further investigation by a nurse practitioner (NP). The NP and care manager—via a virtual call—discovered the patient had been prescribed a new medication by the cardiologist that was causing dizziness. The nurse and cardiologist collaborated to review medication. Through close communication and access to real-time data, they were able to change the course of treatment as needed. Overall, the patient received the proper medication and treatment, resulting in improved health status.
Advanced Care Team: The Nurse Practitioner coordinated care with the care manager and cardiologist.
Remote Patient Monitoring: The patient was monitored closely with the help of a telemonitor.
Key Outcomes
• Worked closely with community partners to deliver coordinated-patient- centered care.
• Advanced clinical oversight and successful utilization of technology allowed the team to problem-solve successfully.
• Patient remained in the comfort of home during recovery.
