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

Diabetes > Monitoring > Plan

Plan

The plan of care should include measurable specific goals that are realistic when monitoring a diabetes plan.
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The patient and/or caregiver needs to have an understanding and knowledge of how to use the blood glucose meter, what their blood glucose reading means, how to obtain supplies.

 Plan characteristics should include:
  • Includes a defined time frame
  • Developed with the patient and include what the patient wants to achieve
  • Considers patient’s readiness to change
  • Outlines the support they need to make changes
  • Includes individualized interventions to meet patient's goals*
    *Under implement you'll find tools to help carry out patient goals
 Important to consider when doing your plan of care:
  • Target goals for A1c (including preprandial and postprandial target goals)
  • Target goals for blood pressure
  • Target goals for cholesterol (LDL, HDL, Triglycerides)
  • Current recommended standards of clinical care

Medicare Part B Covered Diabetic Testing Supplies for Diabetics (Web Page) - Feb 8th, 2011
Medicare covers certain supplies if a beneficiary has Medicare Part B and has diabetes. Full list of what it covers and doesn't, which is helpful for patients and clinicians.

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.

Diabetes: Monitoring Your Blood Sugar Level for Families (Web Page) - Feb 8th, 2011
A great family resources for parents dealing with children newly diagnosed with diabetes from the FamilyDoctor.org.

Lancing Device Reference Guide (Web Page) - Feb 8th, 2011
A one pager updated in 2008 from Diabetes Health about lancing devices currently available.

Diabetes Self Management Behavior Goals (pdf) - Feb 2nd, 2011
Chart for Patient to Write in Behavior Goals to Better Manage Diabetes

 


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.