Complete Care: A Comprehensive Home Health Solution
Profile
Service: Home Health
Diagnosis: Hypertension (HTN), Thyroglossal Cyst, Herniated Discs, Seizures, and Cataracts
Description
A 75-year-old patient was hospitalized due to shortness of breath (SOB), lightheadedness, and dizziness. The assessment indicated high blood pressure (BP) and low heart rate (HR). The patient lived alone with a close family member nearby who provided occasional assistance. Advanced oversight from a nurse practitioner (NP) and successful telemonitoring identified underlying blood pressure issues.
Complete Care Approach
Upon being discharged home, Constellation issued a telemonitor to acquire real-time readings and provide alerts. In addition to skilled nursing care, Constellation provided access to a physical therapist (PT), occupational therapist (OT), and medical social worker (MSW) to improve functionality and discuss long-term planning and support. A follow-up telehealth call with the NP uncovered that the BP had improved but still trended high, and headaches persisted. The NP coordinated communication with the patient’s primary care physician (PCP) and cardiologist to determine the next steps. They established that the patient needed a renal sonogram, which revealed a renal occlusion. After a successful procedure, blood pressure settled within normal limits, headaches were eliminated, and the patient became functionally independent again.
Advanced Care Team: Nurse Practitioner coordinated care with patient’s primary care physician and cardiologist.
Remote Patient Monitoring: The patient was closely monitored with the use of a telemonitor.
Key Outcomes
• Symptoms diagnosed and managed immediately.
• Worked closely with community partners to deliver coordinated-patient-
centered care.
• Advanced clinical oversight and successful utilization of technology led
to the patient’s functional independence.
