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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.
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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
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Best Practice Monitoring and problem solving sections of this Website can be used as guides for developing individualized self-care action plans in order to reduce the risk of exacerbation of symptoms and possible hospital re-admission. Beyond this, risk reduction also refers to reducing the overall risk for further cardiovascular disease. Modifiable cardiovascular risk factors include: hypertension, diabetes, dyslipidemia, obesity, lack of exercise and smoking.
The proactive patient includes prevention screening and immunizations as an important part of their self-care management.
The comprehensive list of preventative screenings and immunizations for adults can be found as the adult preventative guidelines in the following Preventative Services and the CDC's Websites.
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| Assess
(10 documents) |
| Address reducing risk factors for re-admission at each visit in the form of an individualized self-care action plan. |
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| Plan
(4 documents) |
| Include specific, measurable, patient goals in the plan of care. Use “plan characteristics” as tools to build a nursing care plan and find resources to set and reach goals. Consider culture, tradition, individual preferences as well as economic circumstances when creating the plan of care. |
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| Implement
(58 documents) |
| Ongoing communications among all professionals, patient and caregivers is essential to improving and maintaining stability. |
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| Evaluate
(3 documents) |
| Ongoing communications among all professionals, patient and caregivers is essential to improving and maintaining stability. |
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Risk Reduction
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