Heart to Home Transitional Care Program
Heart to Home - Transitional Care Program
Heart to Home - Transitional Care Program
Background
Heart to Home - Transitional Care Program
Heart to Home - Transitional Care Program- The leading cause of death in Oregon and the major cause of heart failure deaths is Myocardial Infarction (MI). The Northwest Regional Heart Center is nationally-recognized for its high standard of care and receives one-third of the MI patients in the metropolitan Portland area.
- Adventist Medical Center is a full-service hospital committed to delivering exceptional, compassionate, whole-person care that nurtures body, mind, and spirit while inspiring trust and confidence.
- We want to impact the lives of our patients by implementing an innovative transitional care program that will provide complete post-hospital services designed to sustain health, facilitate recovery which would lead to fewer hospital readmissions.
Program Goal: To provide enhanced post-discharge support services that will reduce hospital readmission rate of congestive heart failure (CHF) patients:
- Promote patient self care
- Provide practical support to patients and their caregivers
- Reduce the fear and anxiety of going home
- Improve quality of life
Officer Tom Rhodes - Mitral Valve Repair
Officer Tom Rhodes - Mitral Valve Repair
Officer Tom Rhodes - Mitral Valve Repair
Officer Tom Rhodes - Mitral Valve RepairHeart to Home Transitional Care Program Features
- A team led by a full-time registered nurse to coordinate home calls and follow up on hospital discharge plans
- Computer-based program, “Patient Care Manager” to assess and modify patients’ home care plans depending on the physician’s treatment goals.
- Promotion of self care and improved quality of life through medication and symptom management along with diet and exercise education
- Practical advice and support for the patients and caregivers along with community resource referrals
