PrimeCare Home Health Skilled Nursing Services

24/7 On-Call Care Team

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)

Skilled Wound Care

Rehabilitation / Therapy (Physical / Occupational)

Medication Management

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.

IV Infusion

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

Fall Prevention Program