Chronic Care

Henry Ford at Home works closely with patients who have chronic illnesses to help them achieve their goals of leading fuller and more-active lives. Our Chronic Care Management Programs are designed to help patients monitor their condition and provide tools to help manage their condition. As part of the Chronic Care Management Programs, patients receive home health nursing visits from Henry Ford Home Health Care with the option to add Henry Ford e-Home Care services, including remote patient monitoring. Henry Ford at Home also carries a full line of medical supplies and healthy living items through Hart Medical Equipment to support patients with chronic illnesses.

What to expect

Participation in the Henry Ford at Home Chronic Care Management Program begins with an initial visit by a Home Health Care nurse within 48 hours of your doctor’s referral. Nurses and/or therapists will make three to four visits per week for the first two weeks, and will gradually decrease frequency to prepare for discharge from Home Health Care.

A Home Health Care nurse will:

• Make a list of your medications and communicate with your doctor to be sure that he/she knows what medications you are taking.
• Help you make an appointment to see your doctor within one week of discharge.
• Recommend products and services that can improve your ability to care for yourself.
• Work with your doctor to adjust your Plan of Care to prevent you from feeling worse or going back into the hospital.
• Assist you in getting any equipment that you will need to care for yourself after your home health care service has ended.

Your nurse/therapist will teach:

• When to report symptoms to your doctor or go to the emergency department
• Signs and symptoms to be concerned about
• Name, purpose, dose and side effects of medications
• Ways to prevent illness from getting worse
• Measures to improve your ability remain independent at home
• Risk factors relating to your illness
• How to exercise safely and conserve energy
• How to make everyday tasks easier
• Importance of early symptom control to prevent hospitalization

Your nurse/therapist will assess and monitor:

• Your vital signs and breathing
• Your understanding of your medications and disease
• Safety factors in your home
• Your activity levels
• Your ability to be independent at home
• The need for additional services to help you.