Whether the patient is recovering from a myocardial infarction, has chronic heart disease, or chronic obstructive pulmonary disease, our team of clinicians are experienced in developing care plans that meet each patient’s specific needs. Our program is designed to identify patients requiring energy conservation training, education in disease management, medication and nutrition management, adaptive equipment training, and other treatments that will assist in improving independence in activities of daily living.  

Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) patients often have a high rate of hospital re-admissions. Our successful plan to keep patients at home and avoid hospitalizations includes:

Management of Patient Visits: We schedule more visits at the beginning of the patient’s care to provide comprehensive education on the disease process and to intensify the assessment of the patient.

Telehealth: Use of telemonitor units is standard for patients with chronic obstructive pulmonary disease. The units are placed in the patient’s home and allow patients to take vital signs daily and transmit them in real time to a monitor station manned by a nurse in our office.

Education: Education begins from the moment the patient is admitted to our service. Our nurses work with patients and their caregivers in educating them about cardiac and pulmonary disease. We also provide patients with disease management handbooks as an ongoing resource.

Cardiac Patients

We realize that patients with cardiovascular disease need education to manage their illness, so we incorporate specific directives that address the unique protocols for hypertension, angina, myocardial infarction, and congestive heart failure. We also have extensive experience in dealing with post-acute patients, and we understand that patients who have undergone cardiac surgery often struggle with feelings of fear and apprehension, requiring additional assurance and education.

During home visits, our nursing staff and clinicians will educate the patient on topics such as medication, diet restrictions, and controlling risk factors, such as smoking, weight and exercise; communicate with the patient about his status and progress; develop and assist the patient with an exercise plan tailored to the patient’s needs; and educate and actively involve the patient in managing his condition.

Pulmonary Patients

Our pulmonary disease management program strives to ensure that the patient receives a care plan tailored to his needs. The goals are to significantly improve the patient’s ability to manage his condition within the home setting; reduce visits to the physician’s office and emergency department; provide early recognition of appropriate signs and symptoms to allow for faster and easier medical treatment if needed; and improve the patient’s overall health by controlling risk factors.

Our nurses and other clinicians will educate and train the patient and caregiver about various facets of pulmonary disease; develop and assist the patient with a customized exercise plan; monitor vital signs and assess the patient for early signs of infection; provide rehabilitation therapy to assist the patient with functional limitations and energy conservation techniques; and actively involve the patient in managing his condition through continual education.

To Refer or for further information, please call our Intake Department at (781) 338-7900.