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 > Medications > Plan

Plan

The plan of care should include measurable specific patient goals.

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Use “plan characteristics” below as tools to build a nursing plan and find resources to set and reach goals.

 Plan characteristics should include:
  • Includes a defined time frame
  • Developed with the patient and reflects 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

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.

Keep Your Teeth and Gums Healthy (Web Page) - Feb 8th, 2011
An easy to read 20 page booklet from NIDDK, updated in 2008. Too much glucose in the blood for a long time can cause diabetes problems.

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.