- Assess and manage all disease processes to decrease
the need for hospitalizations or doctor’s office visits.
- Educate the patient regarding his/her disease
process with easy to understand visual aids and tools to assist the patient
with managing his/her health needs
- Assess for symptoms of exacerbation of an illness
and notify the physician of the potential problems before serious issues arise.
- Educate the patient on medical devices including
glucometers, oxygen, nebulizers, feeding pumps wound vacs.
- Perform fall risk assessments and implement a fall
reduction plan for those at high risk for falls.
- Provide pain management with the assistance of the
- Assess the patient’s need for assistive devices and
make arrangements for the home delivery of these devices.
- Assess the need for assistance with personal care
and activities of daily living. Set up
home health aide and make referral for provider services if needed.
- RN on call after hours, weekends and holidays to
assist with health needs whenever they may arise.