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Cerebrovascular Accident Disease Management

Overview

The Cerebrovascular Accident (CVA) Disease Management Program is designed to provide care and education related to disease management of CVA to patients and their caregivers. The program will coordinate care for patients under the direction of their physician, and provide ongoing assessment, education, and treatment for specific neurological illnesses including CVA and TIA (Transient Ischemic Attack.)

Components

  • Case management by experienced Registered Nurses who will coordinate the care prescribed by the physician.
  • Assessment of the patient’s status through individualized visits by the home care nurse.
  • Evaluation and education by qualified Physical, Occupational, and/or Speech Therapists.
  • Education about the importance of exercise in treatment of neurological disease, including monitoring for symptoms that indicate when the patient should rest.
  • Interdisciplinary approach to assist patients in coping with the disease process through the use of trained Medical Social Workers.
  • Long term planning and counseling by Medical Social Workers.
  • In-depth instruction of the medications used to treat/prevent reoccurrence of the disease including anticoagulant therapy and antihypertensive therapy.
  • Education related to dietary impact on medications as well as meal planning, label reading, and food choices to manage other co-morbidities.
  • Telehealth monitoring of blood pressure, heart rate, pulse oximetry (oxygen level), weight, temperature, and appropriate disease related questions which are evaluated by a registered nurse.

Outcomes

Each patient will go through the neurological disease management program differently based upon his/her disease process and individual needs. Several indicators will be monitored to assess patient outcomes.

  • Patient’s ability to verbalize understanding of disease process, medications, anticoagulant therapy, and dietary restrictions/impact on effectiveness of therapy.
  • Patient’s compliance with rehabilitation program and assistance with outpatient placement when patient is stabilized.
  • Knowledge of disease management, including functional deficits, optimizing independence in activities of daily living (ADLs).
  • Patient’s compliance with risk reduction strategies such as medication compliance, smoking cessation, and weight reduction.

Warning Signs

  • Sudden weakness of an extremity or side of the body
  • Trouble walking
  • Visual disturbances
  • Slurred speech

Risk factors

  • diabetes
  • hypertension
  • thrombo-embolitic events
  • high cholesterol
  • smoking
  • slurred speech
  • obesity