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Pulse Home Health Care practices skilled health care procedures firmly rooted in the latest research and best practice policies. We routinely mail bulletins to physicians and other medical referral sources to highlight how we help patients and to explain the scientific basis for different services. On our home health website we share selected physician bulletins about Pulse's Home Health Services. If you have questions about how home health could help you, please contact us today.

Making Chronic Disease Management Easier
For Primary Care Practitioners

Home Health Website ArticlesMany practice guidelines for the management of chronic diseases are inconsistent with the time demands of a standard primary care practice.   In a study published in the Annals of Family Medicine (Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 3(3): 209-214.), Ostbye and colleagues calculated that managing just 10 of the top chronic diseases according to practice guidelines for a standard patient panel of 2,500 would require 10.6 hours of clinician time per day.  This does not take into account any of the other chronic diseases this patient panel would have, preventive care, or acute care.   

Of course, it is not the primary care practitioner’s job to do everything - only to make sure everything is done.  Many physicians have discovered that Pulse Home Health Care serves as a useful team member in chronic disease management for an important subset of patients.  Our patient education delivery model involves multiple visits for education of patients, education of caregivers, verification of successful adherence, and monitoring for results.  If you know who among your patients meets homebound criteria, you know which patients you can refer to Pulse Home Health Care for a comprehensive chronic disease management program.  From a practice management perspective, these elements of Pulse’s chronic disease management services may merit consideration:

  • Chronic disease education referrals are usually straightforward cases requiring no care plan oversight work beyond the initial certification paperwork from a physician.
  • Physicians can bill Medicare for the certification of the home health plan of care.
  • Medicare pays 100% of allowable charges from Pulse Home Health Care, so patients incur no additional costs related to our home health services. 

A primary care practitioner’s goals for referring chronic disease management to home health would include:

  • To improve the patient experience and enhance the patient’s self-management skills by expanding the primary care encounter to include home-based follow-up and coaching
  • To enhance the work flow of primary care practitioners by offloading tasks that can be completed by nurses and therapists who are not a cost center to the practice
  • To reduce national healthcare spending by reducing unnecessary declines and complications through enhanced management of high-risk and high utilizing patients.

When you have patients who do not restate their instructions correctly, who demonstrate non-adherence to the management plan, or who are not accomplishing disease management goals, a referral to Pulse for follow-up chronic disease management may be indicated.  In addition to homebound criteria, Medicare requires a new skilled need.  Health regimen teaching typically meets the skilled need requirement, but for it to be a new skilled need, you would look for a situation such as the following:

    • Recently documented worsening of measures  (e.g. high glucose, high blood pressure, greater dyspnea, reduced function)
    • Recently documented non-adherence to the health care regimen
    • Recent exacerbation
    • A documented likelihood of exacerbation in the next three weeks
    • New medications
    • New diagnosis
    • New health care regimen instructions such as diet changes. 


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2325 Severn Ave, Ste 5 Pulse Home Health CareMetairie LA 70001 Pulse Home Health Care(504) 831-7778

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