Chronic Care Management Programs

CHI Health at Home offers many Chronic Care Management programs, each designed by our expert physicians, nurses and therapists. The goal of each program is to prevent future exacerbations, reduce emergent care and re-hospitalization, and improve the quality of life for our patients.

Balance CareLink

Balance CareLink is a comprehensive chronic care management program to provide a consistent, therapeutic plan offering evidenced-based best practice interventions for fall prevention and injury reduction. Through early detection and treatment, falls and injury can be avoided. This program is designed to assist the patient, family and caregiver in identifying fall risk factors and teach them techniques to prevent pain and suffering that occur with falls.

The Balance CareLink program includes skilled nursing, therapy, social work, and home health aides for patients in their home.  An individualized plan of care is essential to avoid future falls and injuries.  

Cardio CareLink

Cardio CareLink empowers and assists patients who have been diagnosed with heart failure and their caregivers in the management of their disease process in their home setting, while improving their overall quality of life. Our comprehensive program emphasizes ongoing monitoring while our clinicians provide education and support. The overall goal is to improve quality of life, prevent future exacerbations, reduce trips to the emergency department, and reduce re-hospitalization. Our specially trained cardiac nurses provide a range of cardiac care services, such as:

  • IV infusions
  • Home therapy
  • Teaching on cardiac medication, diet and lifestyle
  • Telephonic assessments
  • Home monitoring equipment

Designed to assist the heart failure patient, caregiver and multidisciplinary health care team, the Cardio CareLink program is tailored to the individual patient’s overall risk level, symptoms and severity of disease.  

Diabetes CareLink

Diabetes CareLink is a comprehensive chronic care management program to provide a consistent therapeutic intervention plan for the treatment of Diabetes, Type I and Type II. This program is designed to assist the patient, caregiver, and multidisciplinary health care team through the use of evidence-based guidelines and standards of care. The frequency of home care services is tailored to the individual patient’s overall risk, symptoms, and severity of disease. Diabetes CareLink interventions help to prevent complications related to a patient’s disease progress, improve quality of life and reduce the need for hospitalization.

Diabetes CareLink empowers and assists the patient and caregiver to make informed choices about how to manage their diabetes through:

  • Stabilization of their blood sugar while preventing long term complications and disease progression
  • Emphasis on education and support to provide the skill sets necessary for self management of their diabetes
  • Provide teaching on medication, diet and lifestyle, as well as diabetic monitoring

Ortho CareLink

Ortho CareLink is a comprehensive chronic care management program to provide a consistent therapeutic intervention plan for recovery and rehabilitation following a total joint replacement or other orthopedic procedures. The ultimate goals of this program are to improve the ability to safely ambulate and transfer and assist with pain management in order to return our patients to a full and productive lifestyle.

The Ortho CareLink program assists in the transition from onset of an injury or surgery through recovery and includes skilled nursing and therapy for patients in a total rehabilitation program within the comfort of their home. 

Palliative CareLink

Palliative CareLink is a comprehensive program which utilizes a holistic interdisciplinary approach to enhance the quality of life for those patients and family members who are suffering from a chronic or life-limiting illness.  Palliative CareLink increases support in the home environment to improve and maintain the patient’s quality of life through interventions that include support groups, community resources, spiritual and psychological support for the patient as well as their families and caregivers. This program focuses on the relief of suffering and treatment of symptoms so that the patient can focus on what matters most in life instead of the disease.

The Palliative CareLink team includes nurses, social workers, physical, speech and occupational therapists, home health aides and chaplains who are trained in chronic disease management and life-limiting illness.  The Palliative CareLink team also works closely with a patient’s hospice provider to transition care when a higher level of care is desired.

Pulmonary CareLink

Pulmonary CareLink is an innovative chronic care management program designed to provide comprehensive interventions for patients suffering from chronic obstructive lung disease (COPD) and pneumonia. Pulmonary CareLink empowers the patient to manage their disease, improve adherence with smoking cessation and medication management, prevent and treat early exacerbations and prevent emergent care and hospital re-admissions. Specialists provide a comprehensive program that includes medication and lifestyle teaching and monitoring.

Pulmonary CareLink provides comprehensive and multidisciplinary interventions tailored to the patient’s individual overall risks, symptoms and severity of disease through skilled nursing, therapy, social service and home health aides.  Pulmonary CareLink aims to optimize a patient’s functional status and overall quality of life. 

Skin and Wound CareLink

Skin and Wound CareLink is a comprehensive program that provides a consistent, therapeutic plan for the prevention and healing of wounds. This program assists patients and caregivers in the management of wounds from onset to recovery while in their own home. Our treatments emphasize prevention and healing, as well as reduction in the use of emergent care and hospital re-admission.

Our Skin and Wound CareLink program meets the home health quality initiatives from the Centers for Medicare and Medicaid Services (CMS) through our skilled nursing and therapy services.