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‘Eureka!’ — Turning the Corner toward Disease Self-Management

Residential in the Real World

For one Residential Home Health patient struggling with heart disease, RN Julia’s attentive care and teaching became a transformative ‘aha moment.’It happens time and again: We hear good advice, or we know what’s best for us, but we can’t make the change. Then out of the blue, something falls into place, and everything becomes clear. When it comes to disease management, these ‘aha moments’ can make the difference between a patient trying to follow complicated instructions, and successful management of a chronic condition.

For one Residential Home Health patient, managing her heart disease and related symptoms had previously proved to be more than she could handle. But when RN Case Manager Julia entered the picture, her attention to education and empowerment made all the difference. Read on for the story of the ‘aha moment’ Julia inspired, and the transformation that resulted.

Not Ready for Self-Management

The patient had been diagnosed with high blood pressure (hypertension) and congestive heart failure (CHF), a chronic heart condition that can be managed with a combination of medication, self-monitoring, and lifestyle changes. However, Julia soon recognized that her patient had not been equipped with the tools to take charge and manage her condition.

Upon her first visit, Julia looked around and realized that her patient did not have sufficient energy to keep up with housework. The living space was cluttered, a red flag in terms of fall risk. Signs of infrequent cleaning were also worrisome, as kitchen upkeep and proper food preparation are necessary to preserve overall health and independent living.

Julia also discovered that the patient’s weight had increased 15 pounds over her last recorded weight. Because weight gain in CHF represents a critical warning sign, Julia realized that this needed to be better controlled. Talking with the patient revealed her high-salt eating habits, which can worsen CHF symptoms and make the condition harder to control. The patient also demonstrated a lack of understanding about her prescribed medications, and Julia knew she would need more information and guidance to successfully manage her complex regimen.

Making the Complex Comprehensible

Both Julia and occupational therapist Denise worked with the patient’s family to clean the house and keep clutter under control and out of the way. Furthermore, Julia provided instruction on the patient’s medications. Better understanding of the importance of each drug and how it functioned helped the patient to take her medications consistently and on time. Julia also worked to arrange transportation for future doctor appointments, ensuring better oversight by the patient’s cardiologist. Finally, with encouraging coaching and training, the patient was able to make important changes to her diet, and lost that troublesome weight as a result.

Empowerment Leads to Independence

For the first time, Julia’s patient was empowered to self-manage her chronic conditions. Her improved medication management, ability to keep doctor appointments, and successful weight management had improved her health substantially. Moreover, the education and tools Julia provided had made it possible for the patient to live safely at home without the close supervision of home care.

By their final visit, the patient was transformed, living in a clean house and feeling better than she had in a long time. The patient and her family have since kept in touch with Julia, and they happily report that she has never before done this well with disease management; the patient’s cardiologist expressed the same sentiment. Something in Julia’s attentive care and teaching struck a chord in her patient, and this ‘eureka’ transformation had a lasting impression.

To determine whether you or your loved one might benefit from in-home nursing or other home care services from Residential Home Health, call (888)930-WELL (9355) to discuss your specific situation with a Home Care Specialist today, or click here to take our Home Care Assessment.