Designed for the Unique Needs
of Homecare Providers

This site provides homecare clinicians with access to chronic care management models, best practices and downloadable resources for homecare patients.

Heart Failure
Hypertension and Angina
Diabetes

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"The body of knowledge that serves as the rationale for nursing practice determines the areas of specialty to develop as well as the manner in which that knowledge is organized, tested and applied." -Carper, 1978
level 2

Heart Failure > Medications > Plan

Plan

The plan of care should include specific measurable patient goals. Use “plan characteristics” below as tools to build a nursing plan and find resources to set and reach goals.
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 Characteristics of a good plan should
  • Include a defined time frame.
  • Develop a plan reflecting the patient's thoughts on the things they want to achieve.
  • Consider a patient's readiness to change.
  • Outline the support they need to make these changes.
  • Include the individualized interventions to meet patient's goals. *
    *Under Implement category you will find tools to help you carry out patient goals.
 Important to Consider When Creating a Plan of Care
  • Target goals for blood pressure
  • Target goals for cholesterol
  • Target goals for A1c
  • Target dry weight
  • Current recommended standards of clinical care (ATPII, VNCIII, ACCF/AHA 2009 Update, AHA Promoting Self-care in Persons with Heart Failure).
What Does "Medically Necessary" Mean to my Medicare Coverage? (Web Page) - Feb 8th, 2011
A great breakdown of what the term “Medically Necessary" means, a great resource from The Medicare and Medicaid Center.

Patient/Nurse Partnership to Avoid Rehospitalization - Level 3 (doc) - Aug 1st, 2010
Form detailing clinician and patient responsibilities during treatment

Readiness To Change - Level 3 (doc) - Aug 1st, 2010
A chart for patients to indicate what stage of behavior change they are currently in.

Heart Failure Self-Care Behavior Goals - Level 3 (doc) - Aug 1st, 2010
Chart for patients to fill-in their goals for behavior change

 


Levels of evidence
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Level 1
Systematic reviews and repeated studies, thoroughly researched.
Level 2
Experimental (Single or Quasi experimental study) and non-experimental (Exploratory or qualitative study).
Level 3
Recommendations of respected, experienced homecare authorities.
Level 4
Not Recommended.



The development of the hypertension and chronic stable angina project was made possible by a grant from the New York State Attorney General on behalf of the Attorneys General of all 50 states, DC and Puerto Rico from litigation settlement funds to benefit the healthcare needs of consumers with high blood pressure and angina. Original funding for the site was provided in part by US Congress and CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.