Heart SMART is an Ocean Healthcare Network signature program available in several locations, representing a breakthrough in post-acute cardiac care.
The first of its kind in a post-acute setting, HeartSMART provides outstanding treatment for a range of cardiac conditions, including congestive heart failure, post-myocardial infarction, post-coronary artery bypass and valve replacement, and post-cardiac catheter intervention.
The HeartSMART program was developed in conjunction with top cardiac physicians and nurses, and is affiliated with area hospitals. The program is unparalleled in its clinical focus and capabilities, cutting edge equipment, and specially trained staff. Significantly, the program also features extensive and effective patient education, as well as a strong emphasis on preventing hospital readmissions.
Some important features of the Heart SMART Program include:
The Center for Pulmonary Excellence, currently available at Hampton Ridge Healthcare and Rehabilitation, offers a new level of advanced pulmonary care in a post-acute setting.
The Center was developed in conjunction with top pulmonologists and nurses to provide patients with a high level of care and management for a broad range of pulmonary conditions, such as COPD (Chronic Obstructive Pulmonary Disease), pneumonia, and post-tracheotomy, among others.
The Center for Pulmonary Excellence features a stellar clinical team of experienced caregivers trained in the treatment and protocols specific to this patient population. The Center also features state-of-the-art specialized equipment, advanced clinical capabilities, and a comprehensive patient education/training program that is highly effective in preventing relapses and hospital readmissions.
The Center for Pulmonary Excellence is affiliated with area hospitals, and plays a pivotal role in the continuum of care, supporting patient needs and improving clinical outcomes
The Center for Pulmonary Excellence provides the full scope of post-acute care services as well as comprehensive pulmonary-specific services with advanced clinical capabilities. Significant among these is the administration of piped-in oxygen with a capacity of 15 liters per minute, enabling clinicians to deliver 100% oxygen to patients as needed. The Center’s care program addresses a wide range of pulmonary needs, with treatment that includes:
Curavi HealthTM is a revolutionary tele-medicine system that brings physicians to a patient’s bedside – virtually. Curavi HealthTM uses video technology and digital diagnostic tools to render a pinpoint virtual diagnosis.
The patient is “examined” by qualified Board-certified physician who determines a course of treatment. The entire process is done in close collaboration with the attending nursing staff as well as the patient’s regular physician, resulting in seamless care without the trauma and discomfort of an unnecessary ER visit.
Even the most skilled and conscientious caregivers can improve their performance and clinical outcomes with the assistance of healthcare technology.
Abaqis® is an advanced quality management system that has been proven to effectively reduce deficiencies and increase quality of care. Developed by Providigm, Abaqis® utilizes the same assessment and investigation tools that surveyors employ in the Long-Term Care Survey Process (LTCSP).
The interactive system demands input and feedback from caregivers, staff, residents, and family members. Abaqis® seamlessly integrates into the MDS system to accurately compile admission and discharge data on each patient including payor, diagnosis, hospital, practitioner/physician, day of week, shift, number of days post admission.
Based on this and other factors, Abaqis® enables clinicians to pinpoint potential areas of non-compliance, identify root causes of potential deficiencies, follow readmission trends, and implement effective corrective plans. Post-Acute centers in the Ocean Healthcare Network all employ the Abaqis® system, and have found that the program is an invaluable and powerful tool for QAPI initiatives.
Since Ocean Healthcare Network facilities accept admissions 24/7, they maintain a common Readmission Hotline providing trained Patient Care Coordinators standing by to accept qualifying admissions24/7. The service, known as DirectLine, is the only one of its kind marketed directly to Emergency Room personnel as a valuable resource. DirectLine enables ER staff to avoid readmissions by directing clinically appropriate patients to be treated in one of Ocean Healthcare’s post-acute facilities.
In addition to processing admissions around the clock, Ocean Healthcare Network members also accept patient referrals 24/7. This facilitates patients’ expedited discharge from hospitals and reduces the overall costs of healthcare reimbursement.
This signature Ocean Healthcare Network program has made a significant impact in readmission reduction and improved clinical outcomes.
To ensure that patients discharged from a Skilled Nursing facility are receiving proper care, Ocean Healthcare Network members collaborate to provide care options such as Home Health Care, Home-Based skilled Nursing, Adult Day Health Services, Assisted Living Communities, and Hospice Care. The providing caregivers work in tandem with the discharging facility to thoroughly understand the patient’s history and meet their specific care needs.
The Transitional Care Coordination Program effectively bridges the care gaps that commonly lead to the incidence of unnecessary hospital readmission, namely: medication complications, insufficient home health care, inadequate durable medical equipment, and lack of follow-up physician/medical care.
Patients are provided with clear instruction and guidance at the time of discharge. A designated Care Coordinator provides extensive follow-up after the patient is at home to ensure that the patient’s medications, home environment/care, equipment, and medical oversight are thoroughly addressed.
Incorrect medication administration is a leading cause of post-discharge health complications, often leading to readmission. Several Ocean Healthcare Network members have partnered with area pharmacies to implement the Med Ahead Program.
- Personalized Medication Kit – Prepared under the guidance of caregivers, the kit features an easy-to-use tear-off blister-pack ‘Bingo-card’ design with clearly identified dosages and instructions, packaged in a convenient box – ideal for carry-along to physician appointments.
- Pre-discharge patient orientation – A thorough review of all prescription and over-the-counter medications prior to discharge, to avoid duplicates as well as negative drug interaction.
- Free home delivery – Upon discharge, patients have the option of pharmacy delivering Personalized Medication Kit to patient’s home
- Refill delivery – At refill time, the new supply of bingo-card medications in a box will be delivered to patient’s home.
- Free medication review – Upon discharge and at each refill interval as needed, a pharmacist will visit patient’s home for medication reconciliation, reviewing all medications and discarding any that are duplicate or expired.