CHRONIC DISEASE

At its most basic, a chronic disease is a persistent and continual condition that lasts 1+ years, requires ongoing medical attention, limits daily activities, and cannot be prevented by vaccines or cured by medication. 

Living with chronic disease changes the way you live, see yourself, and relates to others.

Living with a chronic disease means having to adjust to the demands of the condition and the therapy used to treat the condition, adding an additional stressors to an already stressful existence.  

Chronic disease in the United States, already highly prevalent, is expected to worsen over the next several decades among all age groups, not just as a result of the Baby Boomer generation aging but also due to increased disease prevalence among children and younger adults. 

The most common chronic diseases in the U.S. (in alphabetical order):

  • ALS (Lou Gehrig’s Disease)
  • Alzheimer’s Disease
  • Asthma
  • Cancer
  • Cardiovascular & Cardiac Disease 
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure (CHF)
  • Cystic Fibrosis
  • Diabetes
  • Epilepsy
  • Stroke
  • Chronic disease can strike at any age, but statistics bear out that such diseases tend to grow more prevalent as a person ages.
  • Approximately 80% of older adults have at least one chronic disease, and 77% have at least two while about 27% of children suffer from one chronic condition, while almost 6 % have 2+ conditions.
  • 6 in 10 adult Americans have at least one chronic conditions while over 3 in 10 have multiple chronic conditions. www.cdc.org
  • By 2025, chronic diseases will affect an estimated 164 million – nearly half of the population. www.fightchronicdisease.org

HELPING OUR PATIENTS MAKE THE MOST OF EVERY DAY.

By establishing the structure of self-care management, we develop a plan for the patient’s future by breaking down the chronic care process into elements and offering a new perspective, one in which they are no longer a recipient of care but an actively-engaged member of the care team.

When a patient is in the position of actively managing their disease, the fear, anxiety and gaps and barriers to care can be significantly lessened, reducing the risk of health decline, loss of independence and unnecessary complications or hospitalizations.

Living with a chronic disease is challenging, but patients who take an active role in their own care can make more informed choices and are less likely to be hospitalized.

Glitches in chronic care often takes place within the gaps and barriers leaving patients with complex medical regimens highly susceptible to negative outcomes, unnecessary complications and avoidable hospital admissions.

DISEASE MANAGEMENT

Tri-County Home Care of Florida supports a solid care plan for our patients that best manages their chronic conditions, achieves more independence and engages patient, physician, specialized professionals and family and/or caregivers for an improved quality of life.

We translate necessary information into a language the patient can understand and educate the patient on best practices for self-care management.  In collaboration with physicians, we bring clarity to patients who might be confused by medical directives and disease information. Our skilled care team helps patients successfully manage medication, symptoms, mobility and other aspects of care.

We provide guidance on managing medications and stress the importance of lifestyle factors such as weight, exercise, and nutrition to ensure a positive outcome in self-care management.

Our goal is to improve the patient’s quality of life and decrease the overall stress level that this condition creates helping patient to control their condition and minimize its impact. We teach our patients about their disease. We help our patients obtain the tools they need to self-manage and to identify red flags for early intervention before their condition or symptoms worsen – promoting greater independence.

We provide detailed assessment and education to help patients successfully manage medication, symptoms, mobility and other aspects of care including physical therapy, special equipment and nutritional education if needed.

We address potential gaps and barriers in care (and their root causes) in order to engage the patient, enhance care and decrease frequent and unnecessary complications or hospitalizations in the long term.  We improve compliance to disease management and treatment plans by addressing the reasons patients may become non-compliant because non-compliant patients aren’t simply ignoring their disease management plans; they usually have a series of barriers keeping them from adherence.

We promote independence as a crucial aspect in helping our patients manage their conditions and avoid setbacks often caused by gaps and barriers to care.

Gaps and barriers to care make it difficult for patients to self-manage and often results in lack of patient engagement, particularly those patients with multiple chronic illnesses and complex medical needs. We help to clarify everything a patient needs to minimize negative outcomes.  


Gaps or barriers to care are major factors in a patient's access to adequate health care and can make successful self-care management of any condition challenging.

Gaps and barriers in care make it difficult for patients to self-manage and often results in lack of patient engagement. These gaps or barriers can range from interpersonal issues such as between a patient and a MD to physical disabilities, emotional, social and mental issues) all of which can lead to a negative outcome. Language, education, cultural and ethnic barriers may also compound the problem.

Patients with multiple chronic illnesses and complex medical needs are highly susceptible to a host of negative outcomes, including medication errors; miscommunication caused by uncoordinated actions; continuation or recurrence of symptoms.

Psycho-Social Factors Creating Gaps & Barriers To Care

  • Patient overwhelmed by fear and confusion following hospitalization or after receiving treatment plan(s) from 1+ MDs can lead to frustration, limited absorption and retention of information communicated.
  • Patient may need more interaction with MD but may be too embarrassed to ask. Poor or incomplete communication creates significant barriers to a positive care experience.
  • 2 in 5 patients with multiple chronic conditions tell their MD about their medical conditions, but not other issues that could affect their health, such as financial and/or transportation issues.
  • Other factors included lack of patient engagement, mental health issues, inadequate education of older adults and their family/caregivers, limited access to essential services, and the absence of a single-point person to ensure continuity of care in the home.
  • Cognitive impairment or deficits, cultural barriers as well as health literacy barriers can also make it difficult for patients to accomplish their goals.
  • Limited access to essential services or technology advancements in MD to patient communication.

Medication mishaps are all too common. With nearly 1/3 of U.S. adults taking 5+ medications, adverse drug events (ADE) account for nearly 700,000 ED visits, 100,000 hospitalizations per year, and represent the most common in-patient error, affecting nearly 5% of patients.  Fatigue, weakness, depression, confusion, pain, and misjudgment often contribute to medication errors that may require hospitalization. 

Medication management assists in getting the right prescriptions to the right individuals, and ensuring medication is taken at the right time. With the guidance of the patient’s MD, our team can develop a customized medication plan to ensure any medication errors are prevented.

Though COVID-19 is still considered to be an acute condition and many people get better within weeks, “long-haulers” (people who continue to experience symptoms that can last months after being infected or may have new or recurring symptoms later, collectively referred to “long COVID” are now classified as a persistent and significant health issue and  as a disability.  

 

Long COVID is a physiological condition affecting one or more body systems.  For example, some people with long COVID experience:

  • Lung damage
  • Heart damage, including inflammation of the heart muscle
  • Kidney damage
  • Neurological damage
  • Damage to the circulatory system resulting in poor blood flow
  • Lingering emotional illness and other mental health conditions

Ensuring safe medication use.
Rx management minimizes the risk of fragmented care, adverse drug reactions, and medication errors for patients requiring multiple medications.

Independence is a key component to positive health management.
P
atients with an active role in managing their health are more likely to stick to treatment plans and often experience improved quality of life.

Patient engagement is a benefit.
Taking active role in managing their health are more likely to stick to treatment plans and often experience an improved quality of life.

Improving quality of life.
We help our patients manage their chronic conditions because enjoying life is so much more than enduring.

Free in-home assessment.
Our RN assesses each patient to determine what services are need, and to identify any potential risks in the home.  

Our qualified caregivers.
Provide quality care to chronically-ill patient to maintain functional ability appropriate to capabilities, lifestyle, and stage of life.

DISEASE MANAGEMENT Specialties

Tri-County Home Care of Florida | Cardiac Care

Cardiac Care

Patients with chronic cardiac conditions — particularly CHF — are often at risk for hospitalization. Our cardiac team uses disease management with a multifaceted approach to stabilize the patient’s condition, reduce re-hospitalizations, increase independence and improve overall quality of life.

Tri-County Home Care of Florida | Diabetes Care

Diabetes Care

Diabetes is a chronic indicator that the pancreas is not producing enough insulin resulting in high blood sugar.  Without effective self-management, it can easily spiral into debilitating and even life-threatening conditions. Disease management helps patients take a more active role in understanding and managing their disease to lessen the need for urgent care and unnecessary hospitalizations.

Tri-County Home Care of Florida | Pulmonary Care

Pulmonary Care

Living with a chronic pulmonary condition affects nearly every aspect of life making it impossible to enjoy that life by significantly impairing the ability to breathe. Some pulmonary diseases are curable, while others are not. Disease management recognizes that all pulmonary diseases are treatable allowing the patient to manage symptoms, preserve independence  and improves their well-being.

Home health care provides necessary clinical care to an individual in their home. It refers to clinical services and support provided intermittently for those challenged by illness, age, disability; or those who are recovering from surgery, or an injury.

For Medicare recipients, a physician must certify that an individual needs home health care, medically necessary services to treat, rehabilitate, sustain or restore home-bound adults and seniors to their optimal health and in the setting where they feel most comfortable.

This includes skilled nursing, disease management, physical, occupational and speech therapy. 

Medicare

Original Medicare Part A typically covers home care services at 100 percent, provided the services are ordered by your surgeon, are performed by skilled professionals and are medically necessary. In addition, the patient must be essentially “homebound,” meaning that it is difficult for the patient to perform activities outside the home, except to go to doctor’s appointments.

Medicare enrollees may be eligible for skilled nursing care, disease management and in-home therapy as prescribed by a physician.  

Private Insurance

Most insurance plans provide some coverage for home care services. But plans, deductibles and out-of-pocket expenses will vary. These plans generally follow the same rules as Medicare regarding payment for long-term care services. If they do cover long-term care services, it is typically only for skilled, short-term, medically necessary care.

Like Medicare, the skilled nursing stay must follow a recent hospitalization for the same or related condition and is limited to 100 days. Coverage of home care is also limited to medically necessary skilled care. Most forms of private insurance do not cover custodial or personal care services at all. Your plan may help you pay for some of the copayments or deductibles. It is best to contact your home care provider of choice prior to your surgery to see if it is in-network with your insurance company. You will also want to contact your insurance company to determine if any pre-authorization is required for home care services.

Short Term and Long-Term Disability Insurance

Disability insurance may pay all or a portion of home health and home care services. It is best to contact your policy provider to determine your coverage.

Private Pay

 

Accredited by The Joint Commission in Broward County.

Accredited by Accreditation Commission for Health Care (ACHC) in Indian River, Martin, Okeechobee, Palm Beach and Port St. Lucie counties.