How it works

• A skilled nurse evaluates the patient and requests additional disciplines – such as physical therapy, occupational therapy, or social work – if these have not already been ordered. They begin teaching the patient about fluid management and symptoms of exacerbation to facilitate the patient’s self management.
• Based on the patient’s criteria, a social worker calls or visits the patient within the first 3 days following discharge to assist in resolving any challenges with obtaining medications, ensuring a caregiver is available or other socioeconomic issues.
• The We’ve Got Heart Program includes a comprehensive medication management assessment to ensure the patient understands their medications, and to alert the patient’s physician of any potential interactions. It also entails detailed patient education on dietary restrictions, reading food labels and weighing in daily to manage weight and fluid retention. A Registered Dietitian can also provide an in-depth consultation with the patient.
• Our Occupational Therapists teach the patient energy conservation techniques, including organizing their daily activities, redesigning tasks and rearranging the layout of their home. Physical Therapists work on strengthening the patient in order to avoid falls and to improve endurance throughout the day.
• A skilled nurse performs a respiratory screen, looking at oxygen deprivation at night as well as Obstructive Sleep Apnea (OSA). The patient’s physician may order an in-depth screening – an overnight oximetry test performed by a Respiratory Therapist. The physician may also order oxygen, if needed, and we provide equipment that is suitable for the patient’s lifestyle.
• Home Medical Equipment (HME), including elevating beds and mobility devices, are available directly from Advanced Home Care. We offer the complete solution for patients with heart failure.
• Infusion Therapy can administer cardiotonic medications to Class 4 patients. IV Lasix, when ordered by the patient’s physician, can be administered by our nurses in the home, reducing rehospitalizations and unnecessary trips to the emergency room.
• Our We’ve Got Heart Care Team provides ongoing telemanagement in between nursing visits in order to assess the patient’s condition and escalate to our Cardiopulmonary Specialist when conditions require intervention.