Chronic disease management at home

You don’t have to manage a chronic disease alone. Aurora Health at Home can help you manage your chronic condition at home through skilled nursing, specialized programs and telehealth.

Take control of chronic disease with our home health services

Chronic conditions require a lifetime of management. That’s why our team doesn’t just focus on stabilizing your health – they teach you how to manage your condition independently. Our in-home chronic disease management includes:

• Patient education: Through nurse visits and telehealth, we teach you how to recognize and assess changes in your symptoms. You learn how to monitor your health and when to call the doctor.
• Virtual health: By monitoring signs such as weight, heart rate, breathing rate and blood pressure, we can catch changes before they become a concern. In fact, studies show that telehealth helps keep you out of the hospital. Learn more about our virtual health program.
• Specialty care for heart conditions: If you’re managing a chronic heart disease at home or recovering from heart surgery, we offer cardiac-focused care, including:
  • Helping Hearts at Home Package: We connect you with a care team specially trained in heart failure management. The team includes in-home nurses, therapists, dietitians and virtual health nurses, so we can meet all your needs.
  • Diuretic heart failure program: We use virtual health to closely monitor your symptoms. We treat you at home if you need diuretic medication to relieve swelling.
  • Rapid recovery program: This two-week program serves as a bridge between open heart surgery and cardiac rehab. Specialty-trained nurses see you three times a week, with virtual health monitoring of vital signs and symptoms between visits. We get you to outpatient cardiac rehab as soon as you’re strong enough.

Personalized home health services for chronic conditions

As part of Aurora Health Care, we’re equipped to manage a wide range of chronic diseases. We can help manage:

• Congestive heart failure (CHF): Our nurses are trained in heart failure management. They review your medications and provide wound care if you’re recovering from surgery. They also educate you about the best diet for CHF. Through virtual health, we teach you how to monitor your weight and vital signs for concerning changes. Learn more about heart failure.
• Chronic obstructive pulmonary disease (COPD): Our nurses monitor your vital signs and symptoms while teaching you how to recognize when the condition worsens. Professionals specially trained in COPD management deliver physical, occupational, speech and respiratory therapy as needed.
• Diabetes: Using virtual health, we monitor your blood sugar and work with you to manage your insulin. Our nurses and dietitians educate you about diet and medication management.
• Neurological diseases: Our nurses coordinate the care you need for a neurological condition such as Parkinson’s disease, amyotrophic lateral sclerosis (ALS), dementia and multiple sclerosis. Our trained providers monitor you in your home for fall risk and provide education for both you and your family. Physical, occupational and speech therapists deliver services as needed. Learn more about neurology at Aurora.

Getting started with in-home chronic disease management

If your doctor prescribes home health services to help you manage a chronic condition, your Aurora Health at Home services begin quickly. You should expect:

• Initial nurse visit: During your initial assessment a nurse evaluates your health, reviews your medications and assesses your home for fall risks. The nurse also answers any questions you have and explains the schedule for your care.
• Coordinated care: A case manager works with therapists, virtual health nurses and other home health services professionals to ensure you receive the right services at the right time. Your medical history and care are documented in a single Electronic Medical Record, which is shared by all Aurora Health Care providers. Your home health services team always knows what you need, and what you don’t.
• Communication with your doctor: Your home health team shares your progress with your doctor. They also immediately pass along any concerns.

Learn more about what to expect from home health services

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