PrimeCare Home Health Skilled Nursing Services
24/7 On-Call Care Team
Rest assured, if our patients ever have a question that can’t wait until morning, a PrimeCare on-call nurse is available to help by calling (903) 248-2530. The Helpline is available 24/7/365, which includes weekdays after-hours, weekends, and holidays. Please be advised that if it is a medical emergency, please call 9-1-1.
Observation & Assessment
PrimeCare Home Health nurses collect systematic patient vitals and visual and verbal assessments each in-home visit to assess a patient’s overall health status. The psychological data collected about the patient’s condition is sent to the primary care provider to determine if the patient’s prescribed care plan is working. Primary assessment includes…
A – Airway
This step involves assessing the patient’s airway. Nurses will observe the patient for dyspnoea, excessive upper respiratory secretions, respiratory problems such as coughing/choking, airway trauma, etc.
B – Breathing
This step involves assessing the adequacy of the patient’s breathing and gas exchange. Nurses will observe patients for dyspnoea, asymmetrical chest wall movements, and changes in breathing sounds.
C – Circulation
This step involves assessing the functioning of the cardiovascular system and whether the patient has adequate blood volume. The nurse will often check the quality and rate of the pulse, capillary refill time, and skin color, and temperature.
D – Disability
This step involves briefly assessing the patient’s neurological system, including their level of responsiveness and alertness.
Vital signs are measured and recorded. The nurse can then progress to the secondary surveys body regions, including eyes, skin, hair, upper extremities, lower extremities, and the neurologic-muscle systems.
General surveys include:
• How alert is the patient?
• How are upper extremities and lower extremities functioning?
• How well are the patient’s voice responses?
• How well is the patient responding to pain?
Chronic Care Management
People with multiple chronic conditions may struggle to manage daily tasks and maintain a balanced lifestyle. With compassion, we recognize patients sometimes need a little extra help. That’s where chronic care management plays a role in filling the gaps in care. In-between nurse visits, care coordinators check-in by phone and video calls to encourage, remind and educate patients to help them manage their daily struggles better.
Follow up calls may include, but are not limited to:
• Personal information including social determinant surveys
• Health goals
• High-risk alerts associated with their condition.
• Manage Health Care providers, Specialist, and Laboratory tests
• Medications management
• Special services needed to manage their condition
• DME medical devices required to manage your care
Both patient and medical care providers face many challenges in chronic care management. As the number of chronic conditions increases in a person, the risk of mortality, hospitalization, and medication interaction increases. Multiple chronic conditions directly contribute to disability.
Patients with multiple chronic conditions usually require more extended, more in-depth, and more frequent doctor’s visits than is typical for acute care. Our care team approach includes an assigned Care Coordinator who will collaborate with your medical professional as needed to help fill gaps in care. To some extent, chronic care management’s goal is to help patients return to daily activities that their chronic conditions prohibited. Ultimately, patients who are more engaged in their health have better managed chronic conditions and less risk for hospitalizations.
Education Patient & Caregiver (Diet / Medication / Exercise)
Good dietary habits, medication adherence, and daily exercise are ongoing education that patients can expect from our PrimeCare nurses. These daily lifestyle habits play a vital role in a patient’s wellbeing. We offer patients and caregivers strategies, including best practices to build confidence and encouragement to take small steps to meet the patient’s goals.
Nurses can assist patients as needed with organizing their weekly medication using PrimeCare provided 7-day medication planners. Medication planners have proved to improve a patient’s adherence to the schedule of taking medicine as prescribed, furthering better outcomes.
PrimeCare nurses also educate in-home caregivers to help assist with diet, medication, and exercise. We recognize the importance of a caregiver’s support, not only in compassion and empathy but also emotionally being available during a patient’s challenging times.
Skilled Wound Care
PrimeCare nurses provide an ongoing assessment process, clinical decision making, intervention, and documentation to help facilitate optimal wound healing. Collaboration between the nursing team and treating physician is essential to ensure appropriate wound management is cared for as directed. Photos and assessments from the in-home nurse communicate to attending physicians the status of the healing process.
Rehabilitation / Therapy (Physical / Occupational)
PrimeCare’s integrated network includes rehabilitation and physical therapy services provided by CORE, the Centre of Rehabilitation Excellence. CORE’s experienced physical therapists and (PTA) physical therapy assistants treat patients with a wide variety of therapy needs, including recoveries from injuries or falls, joint replacement surgeries, cancer treatment recoveries, and stroke-related disabilities. CORE’s therapy plans specialize in decreasing pain while restoring your functional mobility. CORE’s approach recognizes every individual’s uniqueness. Each patient will receive customized therapy with a step-by-step success plan.
Occupational Therapy may include treatments to regain mobility needed to perform daily routines, bathing, walking (including Fall Prevention), and other functional mobility requirements. Physical Therapy may consist of treatment for recovering from an injury, surgery, or short-term disability.
Therapists provide in-home visits usually once-a-week. Therapists update nursing staff and medical providers to ensure the continuity of your care.
Therapy often includes custom exercise programs that can help to:
• Improve overall strength
• Decrease symptoms of illness
• Improve breathing
• Strengthen the heart
• Lower blood pressure
• Improve circulation
• Decrease pain
• Improve sleep and relaxation
• Improve balance
• Reduce risk for falls
Medication Management improves patient outcomes while reducing overall patient prescription costs. At PrimeCare, nurses perform Comprehensive Medication Reviews to ensure medications are not duplicated and taken as prescribed. Medication management can be performed by either the CCM Chronic Care Management team or Home Health Nursing staff. Health assessments are sent to the patient’s physician to determine if the current medications and dosage is working as prescribed to manage their disease state.
Additional Medication Management includes educating patients about their disease. Educating patients about medication benefits help to slow the disease’s progression and avoid their disease complications. Additionally, lab test results are essential to determine medication needs, including blood glucose, hemoglobin A1C, lipids, cholesterol, comprehensive metabolic panel, liver panel, and thyroid.
Intravenous therapy (IV therapy) is a medical technique that delivers fluids, medications, and nutrition directly into a person’s vein. IV therapy is also for rehydration or to provide nourishment for those who cannot consume food or water by mouth. IVs also administer medications, other medical therapy or electrolytes to correct electrolyte imbalances. PrimeCare can coordinate the delivery of IV infusion equipment as prescribed by your physician and assist with installing and setting flow rates. Additionally, training patients and caregivers on IV therapy use and maintenance are available.
Patients requiring long-term support with feeding or short-term extra nutrients to grow and develop will receive special assistance from PrimeCare nursing staff with their medical gastrostomy equipment. Adults with neurological (nervous system) disorders that affect their swallowing, or breathing in of food (aspiration), are candidates for gastrostomy care. Others may have a gastrointestinal (digestive system) disorder that affects how food travels down the esophagus (food pipe) into the stomach requiring gastrostomy care.
Transitional Care Management
When patients are admitted to a hospital, specialty nursing facility, or rehabilitation center, our transitional care management team will provide non-face-to-face services to ensure smooth transitions. The goal of TCM is to improve the patient experience, save health care costs and prevent readmission. Transitional care includes but is not limited to the following:
• Start Discharge at the Time of Admission
• Ensure Medication, Education Access, Reconciliation & Adherence
• Arrange Follow-up Appointments with PCP
• Arrange Home Healthcare & Care Plan Oversight
• Have Patients Teach-Back the Transitional Care Plan
Ostomy care is a condition that often stresses patients initially as it is not a natural function. Caring for colostomies, ileostomies, or other incontinence issues requires special medical supplies. PrimeCare nurses can assist with inspecting ostomy insertion sites to prevent infection and ensure proper function.
Fall Prevention Program
Falling at home is one of the leading causes of fatal and non-fatal injuries and hospital visits for trauma among older adults. The fear of falling limits patients’ activities and social engagements. It leads to physical decline, depression, and isolation. PrimeCare nurses, as well as Physical Therapists, offer in-home preventative suggestions to keep you safe, including hand-rails, door stops, floor covering removals, lighting, and accouterments suggestions.
Providing Home Health in the following Texas Counties