title: A disease management program for heart failure: collaboration between a home care agency and a care management organization.
abstract: This article describes a collaborative approach to manage patients with heart failure between a home care agency and a care management agency. The resulting disease management program used a combination of home visits and phone contact. Care management plans emphasized patient education on increasing adherence to medical and diet regimens, and recognizing early symptoms of exacerbation that could lead to rehospitalization. Clinician activities and patient outcomes are described.
authors.affiliation: Covenant Home Health and Hospice, Milwaukee, WI, USA.
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Gorski
authors.forename: Kathy
authors.initials: K
authors.lastname: Johnson
mesh_terms: D019090:Case Management / Q000458:organization & administration*; D003266:Continuity of Patient Care / Q000458:organization & administration; D003299:Cooperative Behavior; D019091:Critical Pathways / Q000458:organization & administration; D019468:Disease Management; D006333:Heart Failure / Q000453:epidemiology / Q000628:therapy*; D018574:Home Care Agencies / Q000458:organization & administration*; D006801:Humans; D007373:Interinstitutional Relations; D009720:Nurse Clinicians / Q000458:organization & administration; D024802:Nurse's Role; D010043:Outcome and Process Assessment, Health Care; D010349:Patient Compliance; D010353:Patient Education as Topic; D010359:Patient Readmission; D016730:Program Development; D015397:Program Evaluation; D013689:Telephone; D014922:Wisconsin / Q000453:epidemiology