FIRST HOME VISIT. What barriers do you feel you may have in following these instructions?

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1 FIRST HOME VISIT Clinical Assessment Perform initial comprehensive assessment including. BP: take in both arms. Arm should be supported and not dependent. Determine which arm has higher reading. This is the arm to use for BP in the future. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark) measurements in cms. Weigh patient and teaching includes the importance of daily consistent time weight taking and logging. Refer to Page 27 CFYH. Assess patient s ability to use scale and document correct weight. TARGET weight: round up i.e = = 181. Document Target Weight in pts. copy of CFYH. Medications: Assess evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and any barriers identified. ADLs/IADLs: Assess patient s ability to manage A.D.L.s, available caregiver support. Assess whether pt. would benefit from Rehab services for energy conservation assessment and teaching, Home Exercise Program, etc. Patient/Caregiver Assess patient/caregiver knowledge of Caring for Your Heart: Living Well with Heart Failure (CFYH) book. Page 1 Tell me what you know about Heart Failure 1 Begin Self Management teaching/discussion using Page 2. What barriers do you feel you may have in following these instructions? Medication Reconciliation: Assess patient s knowledge re meds Teach at least 2 high risk medications including one diuretic (Page 7 CFYH). Use Pages 3-8 CFYH as teaching tools w/patient. Have them think about & write in idea log on Page 8. For patients on ACE Inhibitors instruct not to use salt substitutes because they have high levels of Potassium, and ACE inhibitors retain Potassium. CFYH General: Introduce Page 22, Daily Check-Up Review Page 29, When Should I Call Encourage pt/caregiver to read, review Pages and write down ideas and/or questions on Page 30. As always with initial visits, confirm the patient/ caregiver has the correct phone numbers to contact you and the hospital and understands how to triage/who to call with questions. Goals of program - inform pt/cg of goals: Avoid rehospitalizations Independent disease management. DC Planning: Discuss MD ordered visit frequency 3w1,2w1,1w2. Set up next visit. Reports: If no scale in home, speak to your A.D.N. and develop plan to obtain one. 2 Report case open to A.D.N. Provide report to CARE MAN- AGEMENT (CM) 3 nurse on all cases, whether CM patient or not 4. Call ordering MD reporting case open, clinical findings outside parameters, medication discrepancies. Request verbal orders for needed supplies/services/ disciplines For inpatient discharges: If no cardiology appointment set up 7 days after hospital d/c, call Jenny (Yevgenia Tartakovsky ) at For Cardiology Clinic referrals, ensure Medical Clinic appt has been set up within 30 days. OASIS: Complete with all documents in admission packet as appropriate. I.O.: After obtaining Verbal Orders from MD, write Interim Orders for any changes to the Plan of Care. Managed Care Report: Complete managed care report if needed. Teaching: Document all teaching specifically using page numbers in CFYH booklet. Med teaching includes names of medications. Self Management: includes patient/ caregiver ability to self manage, any barriers identified, knowledge deficits, and all teaching planned for next visit. 1 Questions in this font are ideas on how to begin visit. Use as appropriate 2 Refer to Protocol for Obtaining Scale 3 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 4 Refer to Standard Work on between Home Care and House Calls

2 SECOND HOME VISIT Clinical Assessment BP: Take in arm identified in prior visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark) measurements in cms. Review Weight Log on last page of CFYH. All subsequent weights are now rounded down, i.e., = = 180. Refer to Page 29. If patient s weight is up 4 pounds or more from Target Weight, Medical Clinic is called Identify self as HF patient and request immediate appt. Medications: Assess medication compliance, any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered meds, identify barriers to compliance. Patient/ Caregiver Ask patient/caregiver how they are doing and if they have any questions. How are you feeling today? What would you like to discuss regarding your heart health today? 5 Daily Check up CFYH: Assess patient/caregiver s use pp CFYH. Review Page 30, ideas and questions. Ask patient for teach back on Pages CFYH. Identify and address any barriers. If patient/ caregiver has experienced any symptoms described on those pages, listen, assess and teach. Contact MD if clinically indicated. Medications: Ask to see all medication bottles and ask patient for teach back regarding meds taught at prior visit. Reinstruct as needed. Review pp 3-7 CFYH. Review pt/caregiver writing on Page 8 CFYH. Teach at least two more medications, if patient is taking more medications. Nutrition: Introduce concept of dietary intake on pps CFYH. If possible, use foods in home as teaching tools with CFYH, especially pages 14 and 15, which have Food Labels. Ask patient to provide a 24 hour dietary recall. Review Page 16 with patient to identify small changes they are willing to make. Emergency Instructions: Reiterate instructions on page 29 CFYH AND When to Come to ER or call 911, on page after page 30 of CFYH. Communication / -If CARE MANAGE- MENT 6 patient and equipment has been delivered, ask patient/ caregiver to demonstrate use of equipment. - CARE MANAGEMENT: Contact CM nurse at least weekly (Mon. preferred) whether CM patient or not, with any changes to POC or other significant findings. Obtain report from CARE MANAGE- MENT nurse if CM patient. 7 -If any assessments are out of parameters, contact MD for verbal orders and/or instructions. -Make appointment for next visit. Be sure to ask pt/cg about other appts. Remind pt/cg about visit frequency. Complete Skilled Visit Note. Document specifically all assessments & teaching in Cardiovascular section of Note. All other areas of note to be completed as appropriate, based on other deficits and/or comorbidities. Skilled Care - P. 4 of Note is completed regarding all teaching & assessment not in Cardiovascular area. Document all collaboration with CM, MD and/or other services. Refer to CFYH in Written Instr Re, and Outcome to Care. Include patient/ caregiver s understanding and ability to learn and manage as well as any barriers to learning. Examples of specific documentation: Pt/cg able to provide return demo on daily weights. Need further instruction on completing weight log Patient able to identify HCTZ and state when to take and side effects, but did not remember teaching from prior visit on side effects of Vasotec. Began teaching food labels to identify sodium content. Progress summary includes areas still to be assessed and taught specifically those noted in examples above. Plan next visit should identify areas to be assessed and taught at next visit. 5 Questions in this font are ideas on how to begin visit. Use as appropriate 6 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 7 Refer to Standard Work on between Home Care and House Calls

3 BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle/ calf (consistent 20 cms. above ankle bone mark) measurements in cms. Review Weight Log on last page of CFYH. All weights are rounded down, i.e., = = 180. Refer to Page 29. If patient s weight is up 4 pounds or more from Target Weight, Medical Clinic is called Identify self as HF patient and request immediate appt. Medications: Assess med. compliance, any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered meds, identify barriers to compliance. THIRD HOME VISIT Patient/ Caregiver Ask patient/caregiver how they are doing and if they have any questions. How have you been feeling since our last visit? What would you like to discuss today? 8 Ask if Cardiology appt has occurred yet. Ask patient/caregiver to report what occurred at appointment. If there were any new medications prescribed, call MD to collaborate and obtain verbal order and write I.O. Begin teaching those changes. Daily Check up CFYH: Reassess patient/cg use pp CFYH. Identify and address any barriers. Medications: Ask to see all medication bottles and ask patient for teach back regarding meds taught at prior visit. Reinstruct as needed. Teach any medications not taught at prior visits. Review pp 3-8 including patient/cg s documentation on p. 8 CFYH. Identify barriers to learning and address. Nutrition: Assess pt/cg s understanding of pps CFYH. Ask for teach back, if possible using foods in home as teaching tools with CFYH, especially pages 14 and 15, which have Food Labels. Assess any barriers to change and address. Exercise: Introduce pp in CFYH. Use p. 21 to develop goals. Ask pt/cg to write plans for exercise on p. 21. Communication / CARE MANAGE- MENT (CM) 9 : Contact CM nurse at least weekly (Mon. preferred) whether CM patient or not, with any changes to POC or other significant findings. If CM patient, obtain report from CM nurse on their findings. 10 If any assessments are out of parameters, contact MD for verbal orders and/or instructions. Make appointment for next visit and remind patient that you will be visiting 4 more times Complete Skilled Visit Note. Document specifically all assessments and teaching in Cardiovascular section of Note. All other areas of note to be completed as appropriate, based on other deficits and/or comorbidities. Skilled Care on P. 4 of Note is completed regarding all teaching and assessment not in Cardiovascular section. Document all collaboration with CM, MD and/or other services. Refer to CFYH in Written Instr Re, and Outcome to Care. Include patient/ caregiver s understanding and ability to learn and manage as well as any barriers to learning. Examples of specific documentation: Pt/cg demonstrated ability to achieve daily weights and now can document weights accurately Patient now able to teach back on Vasotec and is compliant with meds as ordered. Pt/cg demonstrated use of food labels to identify sodium. Pt beginning to slowly give up added salt. Pt/cg using Daily Check Up daily. Pt stated this helps me to remember to pay attention. Progress summary includes areas still to be assessed and taught specifically those noted in examples above. Plan next visit should identify areas to be assessed and taught at next visit. 8 Questions in this font are ideas on how to begin visit. Use as appropriate 9 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 10 Refer to Standard Work on between Home Care and House Calls

4 BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle/calf (consistent 20 cms. above ankle bone mark) measurements in cms. Review Weight Log on last page of CFYH. All weights are rounded down, i.e., = = 180. Refer to Page 29. If patient s weight is up 4 pounds or more from Target Weight, Medical Clinic is called Identify self as HF patient and request immediate appt. Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and identify barriers to compliance. FOURTH HOME VISIT Patient/Caregiver Ask patient/caregiver how they are doing and if they have any questions. How have you been feeling since our last visit? What would you like to discuss today? What changes occurred since our last visit? 11 Provide positive feedback for any changes patient/caregiver has begun including: Any changes are a big success. If patient/caregiver has been able to make changes in some areas & not in others after giving positive feedback about changes, discuss barriers that impact ability to make other changes. Explain that change takes time and help patient/caregiver to develop short and long term goals for change. In CFYH, review as needed: Exercise pp As exercise was just taught at last visit, this may be the focus of your teaching. Assess barriers to change in all above areas and address. If CARE MANAGEMENT (CM) 12 patient, equipment should be in home, fully operational. If not done at prior visit, ask patient to demonstrate use of House Calls equipment. CARE MAN- AGEMENT: Report assessment to CM nurse at least weekly (preferably Mon.), whether CM patient or not. Collaborate regarding patient/caregiver s progress including: learning, compliance w/meds, weights, diet. Ensure CM nurse aware of all barriers identified. If CM patient, obtain report from CM nurse re findings. 13 parameters, contact MD for verbal orders and/or instructions. Make appointment for next visit. Be sure to ask pt/cg about other appts. Remind pt/cg of visit frequency. If Care Management patient, you can assure them that the CM nurse will continue to work with them. Complete Skilled Visit Note. Document specifically all assessments and teaching in Cardiovascular section of Note. All other areas of note to be completed as appropriate, based on other deficits and/or comorbidities. Skilled Care on P. 4 of Note is completed regarding all teaching, assessment not in Cardiovascular section. Document all collaboration with CM, MD and/or other services. Refer to CFYH in Written Instr Re, & Outcome to Care should include patient/caregiver s understanding, ability to learn & manage as well as any barriers to learning. Progress summary includes areas still to be assessed, taught. Examples of specific documentation: Pt/cg demonstrated is now familiar with CFYH. Needs further instruction/coaching on integrating exercise into daily life Pt has stopped adding salt at most meals. Understands importance. Pt forgot to weigh and record twice this week. Reinstructed on importance and verbalized understanding and compliance. Pt/cg have begun walking daily for 10 mins. Plan next visit should identify areas to be assessed and taught at next visit. 11 Questions in this font are ideas on how to begin visit. Use as appropriate 12 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 13 Refer to Standard Work on between Home Care and House Calls

5 BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark) measurements in cms. Review Weight Log on last page of CFYH. All weights are rounded down, i.e., = = 180. Refer to Page 29. If patient s weight is up 4 pounds or more from Target Weight, Medical Clinic is called Identify self as HF patient and request immediate appt. Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and identify barriers to compliance. FIFTH HOME VISIT Patient/Caregiver Ask patient/caregiver how they are doing and if they have any questions. How have you been feeling since our last visit? What would you like to discuss today? What changes occurred since our last visit? 14 Continue to provide positive feedback for any changes patient/caregiver has begun including: Discuss barriers that impact ability to make changes. Remind that change takes time and help patient/caregiver to develop short and long term goals for change. In CFYH, identify areas which need reinforcement, reinstruction and provide same. Do pt/cg understand these are changes for life? How will they maintain change? Exercise pp Weight log CARE MANAGE- MENT (CM): 15 Whether CM patient or not, report assessment to CM nurse at least weekly (preferably Mon.) and collaborate regarding patient/ caregiver s progress including: learning, compliance with medications, weights and diet. Ensure CM nurse is aware of any barriers you have identified for further education and coaching. If CM patient, obtain report from CM nurse on their findings. 16 parameters, contact MD for verbal orders and/or instructions. Ensure Medical Clinic appointment is set up and pt/caregiver knows when appointment is. Make appointment for next visit. Be sure to ask pt/cg about other appts. Remind pt/cg about visit frequency. Ask pt/cg to think about any areas in which they need more teaching or information. If they have CM, you can assure them that the CM nurse will continue to work with them. Complete Skilled Visit Note as specified at prior visits (See visits 1-4) Examples of specific documention: Pt/cg using Daily Check Up in CFYH every day. Cg verbalized concern re continuing to remember meds. Teaching provided re P. 8 CFYH to prompt pt/cg to document ideas to sustain medication compliance. Pt continues to weigh daily and document same. Pt/cg sustaining daily walks and have increased time from 10 mins to 15 mins. Plan next visit should identify areas to be assessed and taught at next visit. 14 Questions in this font are ideas on how to begin visit. Use as appropriate 15 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 16 Refer to Standard Work on between Home Care and House Calls

6 BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark) measurements in cms. Review Weight Log on last page of CFYH. Observe patient weighing self. All weights are rounded down, i.e., = = 180. Refer to Page 29. If patient s weight is up 4 pounds or more from Target Weight, Medical Clinic is called Identify self as HF patient and request immediate appt. Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and identify barriers to compliance. SIXTH HOME VISIT Patient/ Caregiver Ask patient/caregiver how they are doing and if they have any questions. Remind them that your next visit will be your last visit. "What would you like to discuss today? What changes have occurred since our last visit? 17 Provide positive feedback for any changes pt/cg have begun, no matter how small, including: Discuss barriers that impact ability to make changes. Remind that change takes time and help pt/cg develop short and long term goals for change. Ask pt/cg to continue to think about what they need from you prior to your next and last visit. In CFYH, identify areas which need reinforcement, reinstruction and provide same. Does pt/cg understand these are changes for life? How will they maintain change? Exercise pp Weight log CARE MAN- AGEMENT (CM): 18 Whether House Calls patient or not, collaborate with CM nurse at least weekly (preferably Mon.) and communicate/ collaborate re any changes to POC. If CM patient, obtain report from CM nurse on their findings. 19 parameters, contact MD for verbal orders and/or instructions. If there is medical necessity to continue visits, collaborate with MD, obtain verbal order, speak with your A.D.N., write I.O. and Managed Care Report to obtain auths if patient has managed care and submit documentation immediately. Ensure Medical Clinic appointment is set up and pt/caregiver knows when appointment is. Complete Skilled Visit Note as specified at prior visits (See visits 1-4) Specific documentation is required. Examples follow: Pt/cg demonstrated full familiarity with CFYH and pt stated today The Daily Check Up is my bible. Pt has stopped adding salt at all meals. Understands importance. Pt taking meds as ordered. Pt/cg has full understanding of purpose, dose, route, frequency and side effects to report for all meds. Pt weighed and recorded every day in last week. Verbalized understanding of importance of this. Pt/cg have begun walking daily for 10 mins. Will discuss other exercise ideas at next visit. Plan next visit should identify areas to be assessed and taught at next visit. 17 Questions in this font are ideas on how to begin visit. Use as appropriate 18 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 19 Refer to Standard Work on between Home Care and House Calls

7 BP: Take in arm identified at first visit. Using that arm, take BP in the sit/stand mode or supine/ sit mode. Lung auscultation: Assess all lung fields for crackles, wheezes, rhonchi. Dyspnea: Assess level of dyspnea at rest and with activity. Chest pain: Assess any episodes of chest pain and actions taken. Edema: Assess/document bilateral ankle and calf (consistent 20 cms. above ankle bone mark) measurements in cms. Review Weight Log on last page of CFYH. Observe patient weighing self. All weights are rounded down, i.e., = = 180. Refer to Page 29. If patient s weight is up 4 pounds or more from Target Weight, Medical Clinic is called Identify self as HF patient and request immediate appt. Medications: Assess medication compliance and any evidence of medication side effects and/or electrolyte imbalance. Assess patient adherence to ordered medications and identify barriers to compliance. SEVENTH HOME VISIT Patient/ Caregiver Ask patient/caregiver how they are doing and if they have any questions. Remind them that this will be your last home visit. "This is my last visit. What would you like to discuss today? Let s talk about your successes. How do you think you ve changed and what do you think you ve learned since we began working together? What about areas you still need to grow regarding taking care of your heart. Would it be OK if we talked about some of them? 23 Summarize the month you ve spent working with them. Provide positive feedback for any changes pt.cg have begun, no matter how small, including: Discuss barriers that impact ability to make changes. Remind that change takes time and help patient/caregiver to develop short and long term goals for change. In CFYH, identify areas which need reinforcement, reinstruction and provide same. Does pt/cg understand these are changes for life? How will they maintain change? Exercise pp Weight log CARE MAN- AGEMENT (CM): 24 Whether CM patient or not, collaborate w/cm nurse. Ensure CM nurse is fully aware of patient/ caregiver s progress including: learning, compliance with medications, weights and diet. Ensure CM nurse is aware of any barriers you have identified for further education and coaching. If CM patient, obtain report from CM nurse on their findings. 25 parameters, contact MD for verbal orders and/or instructions. If there is medical necessity to continue visits, collaborate w/md, obtain verbal order, speak w/your A.D.N., write I.O. & Managed Care Report to obtain auths if patient has mgd. care & submit documentation immediately. If CM patient, assure pt/cg that the CM nurse will continue to work with them. Ensure Medical Clinic appointment is set up and pt/caregiver knows date/time of appt. Complete Discharge OASIS and Discharge Summary. Specifics on your clinical note may includes some of the following examples: Pt/cg will continue with CM services. Pt s BPs and weights have ranged from to during care episode. There was one episode of weight gain outside of parameters and pt s diuretic was adjusted at Medical Clinic. Pt/cg has learned many new skills to manage pt s disease. Pt. now uses CFYH as a daily tool. Pt/cg use The Daily Check Up in CFYH daily. Pt has stopped adding salt at all meals. Understands importance. Pt taking meds as ordered. Pt/cg has full understanding of purpose, dose, route, frequency, side effects to report for all meds. Pt/cg has sustained walking daily for mins. Plan to begin stretching and dancing at home. 23 Questions in this font are ideas on how to begin visit. Use as appropriate 24 CARE MANAGEMENT (CM) is Health & Home Care s Care Management, also known as House Calls Telehealth. Contact info on cover of this document. 25 Refer to Standard Work on between Home Care and House Calls

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