Complete Care: A Comprehensive Home Health Solution
Profile
Service: Home Health
Diagnosis: End-Stage COPD,
Pneumonia, Bronchiectasis,
and CHF
Definition
This 66-year-old patient was part of Constellation’s Pulmonary Program and overseen by a pulmonologist, nurse practitioner (NP), and respiratory therapist (RT) working together to provide specialized care. Upon assessment of the patient, our pulmonologist ordered medication to reduce anxiety related to their respiratory symptoms, thereby reducing anxiety-related increases in shortness of breath. Our RT helped to manage the symptoms and by educating the patient on symptoms of infection and medication maintenance.
Complete Care At Home
Our interdisciplinary, complete care approach kept this patient out of the hospital several times. On one occasion, the patient called the doctor’s office with an exacerbation of symptoms, and they suggested a trip to the ER. Our NP was able to intervene and keep the patient safely home. On a subsequent visit, a physical therapist (PT) noticed weight gain, increased sputum, and decreased SaO2 while on oxygen. The PT called in the NP who was able to treat with antibiotics and adjust medications to avoid hospitalization.
Advanced Care Team: The NP called the patient’s provider office to coordinate care.
Virtual Visits: The closely monitored patient had a telemonitor in place.
Key Outcomes
- Pulmonologist helped drive successful results through physician to physician advocacy for patient.
- Advanced Clinical virtual oversight intervention avoided hospitalization and minimized exposure to Covid 19.
