Disease Management

Disease Management
Visiting Nurse Association of Southeast Michigan’s Disease Management programs provide a formalized plan of care for each patient. VNA's Disease management programs incorporate state-of-the-art technology, dedication to clinical excellence and old-fashioned caring. Our patients receive the care that helps them not only understand their illness but also achieve the best health possible.

TeleHomecare for Heart Failure, Hypertension, Diabetes and COPD
Visiting Nurse Association of Southeast Michigan’s TeleHomecare program sets the standard for improved care of the homebound patient while helping physicians more effectively utilize their time and resources. VNA’s TeleHomecare program is an excellent enhancement to VNA’s already comprehensive cardiopulmonary program and diabetes teaching and education.

Depending on the patient's health needs, the system is designed to proactively detect subtle changes in the patient’s weight, pulse and blood pressure for heart failure, changes in blood pressure for hypertension, and changes in blood glucose levels for diabetes.

VNA uses remote monitoring technology to augment the traditional team approach between the physician, the patient and the nurse for enhanced quality of care. This well-researched approach to care can dramatically impact the patient’s ongoing wellness. Positive clinical outcomes include reduced hospitalizations and treatment of exacerbations as well as patient empowerment and greater understanding of the disease process. Best of all, during the patient's episode of care, this value-added service is provided at no cost to you or your patient.

A 120-day pilot study concluded that the TeleHomecare Program for Heart Failure virtually eliminated hospitalizations and emergency room visits. The Program has received international recognition from the Association of Telehealth Services Providers.

Patient Benefits

	Decreased emergency room visits and rehospitalizations.
	Feeling of security in continuous monitoring and availability of the nurse.
	Improvement in functional capabilities.
	High degree of satisfaction in medical care.
	A sense of receiving more care.
	Progression toward self-care when appropriate.
	Higher level of awareness and understanding of disease process and treatment.

Physician Benefits

	Improved patient management.
	More efficient use of time and resources.
	Concise reporting of clinical data.
	Trending of physiologic parameters (daily blood pressures, pulse or blood glucose levels).
	Documentation/data to support diagnostic studies/decrease invasive studies.
	No cost to you or your patient.

Patient Population
Homebound individuals who will benefit from this program include those:

	With congestive heart failure
	Requiring hypertension management
	Undergoing cardiac rehabilitation
	Insulin-dependent diabetes (Must be living in Oakland/Livingston counties during the pilot program
	Insulin-dependent diabetes (Must be living in Oakland/Livingston counties during the pilot program
	COPD
	Combined disease states such as COPD and hypertension

The Process

	The physician identifies a patient for VNA’s TeleHomecare program and determines the parameters for weight and blood pressure or blood glucose.
	VNA instructs the patient on the installation and use of the equipment.
	The patient uses the home monitoring equipment daily to take his or her readings as directed.
	Daily, the data is sent via phone line from the patient's home to a secure Web site and stored in a database.
	The data is monitored daily. If a reading falls outside of established parameters, a VNA nurse is notified and follows up with the patient. If the patient consistently falls outside of parameters, the nurse notifies the physician.
	Trended patient reports are available either in hard copy or by supplying the physician with a unique identification number and password to access the data online.

How to Refer a Patient for TeleHomecare Monitoring

One call to VNA is all that is needed to initiate service. To make patient referrals, call (800) 852-1232.