Post-Discharge & Chronic Conditions Management

Who This Service Is For

  • Hospital discharge patients

  • Heart failure (CHF)

  • High-risk diabetes management

  • COPD or chronic lung disease

  • Hypertension

  • Post-pneumonia recovery

  • Patients with frequent ER visits

  • Adults needing medication oversight

What’s Included

  • Vital signs assessment

  • Oxygen/respiratory evaluation

  • Blood glucose monitoring

  • Medication review & education

  • Fall risk screening

  • Intake/output fluid balance assessment

  • Edema monitoring

  • Skin integrity surveillance

  • Early complication detection

  • Communication with primary physician/NP

What to Expect During Your Visit

  • Your nurse arrives at your home and will:

  • Review hospital discharge instructions

  • Verify medications, dosing, timing, interactions

  • Assess oxygen needs, breathing pattern, lung sounds

  • Evaluate hydration, swelling, fluid retention

  • Monitor blood sugar trends and insulin scheduling

  • Screen for complications requiring escalation

  • Provide education for patient & caregiver

  • Document findings for provider continuity

Benefits

  • Prevents unnecessary ER visits

  • Reduces hospital readmissions

  • Improves medication safety & adherence

  • Provides patient & family reassurance

  • Early detection of worsening conditions

  • Reinforces the doctor’s care plan