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All About Home Health

All About Home Health

Home Health Care Services

for the Central Virginia Area

​Disease Management

Our Disease Management Program is designed to support patients with chronic and complex illnesses to reduce or manage symptoms and avoid unnecessary hospitalizations or re-hospitalizations. Our specially-trained teams of nurses, therapists, social workers, mental health clinicians and home health aides understand the challenges faced by patients with a chronic illness. We mobilize our specialized clinical resources to ensure each patient achieves and maintains the best possible level of independence and quality of life. 

Trained in chronic disease management, clinical teams of nurses, therapists, home health aides, life skills advocates, social workers and mental health clinicians provide specialized services to patients with a wide variety of chronic diseases including cardiac and pulmonary conditions, diabetes, stroke and cancer to ensure they achieve and maintain the highest level of functioning.

​Key Features

  • Collaboration with hospital or rehab staff, family and the patient prior to discharge to develop a comprehensive plan of care, with patient-centered goals, focused on ensuring patient safety at home.  

  • Close monitoring of the patient’s progress and achievements to ensure continued improvement and stabilization. To avoid rehospitalization, whenever possible, the clinical team may recommend care at designated long-term care facilities for medication or symptom management and stabilization.

  •  On-site consultation prior to facility discharge for patients identified at high risk for rehospitalization.

  • Palliative care consultation for the management of pain and/or other symptoms and assistance to achieve patient-identified goals of care

  •  Referrals to Hospice, when appropriate, for patients in need of comprehensive end-of-life care.

  • Private care services to support the transition home; homemaker, personal care homemaker and home health aide services are options that can be accessed independently or in conjunction with nursing and specialty services.

Specialized Clinical Teams include

  •  Chronic disease management team includes nurses and physical, occupational and speech therapists with expertise in heart failure, COPD, diabetes, and other chronic illnesses.

  •  Behavioral health team includes licensed independent social workers, psychiatric nurses and licensed mental health clinicians who can assist patients and caregivers in setting realistic goals and adjusting to changes in their condition, living arrangements, limitations and lifestyle. 

  • Clinical specialists includes certified diabetes educators, registered dieticians, wound and ostomy certified nurses, physical therapists qualified to use multiple modalities, occupational therapists with low-vision training and registered nurses certified in infusion therapy.

  • Home support team includes home health aides and life skills advocates for coaching, personal care, transportation, advocacy and assistance with ADLs.