Dealing with a serious chronic illness is one of the most difficult challenges a patient and family can face. Fear about the illness; managing symptoms and pain; complex medical decisions; and controlling frequent trips to the ER and hospital. At Home Support’s Advanced Illness Management program is here to help. Our primary goal is to provide a high level of supportive care to you and your family as you progress through your illness and to ensure that you receive the care you want and need within the comfort of your own home at the time you need it most.
At Home Support services are targeted toward patients suffering from serious chronic illnesses such as cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), advanced dementia, and amyotrophic lateral sclerosis (ALS). The supportive care services are most appropriate for patients with advanced stages of these diseases.
At Home Support services are designed to ensure that you receive the supportive care you want within the comfort of your own home at the time you need it most. At Home Support assigns each patient an interdisciplinary team of clinicians that include an RN case manager, a master social worker, a patient family assistant and a core set of trained volunteers. This team will remain the same throughout your enrollment within the At Home Support Advanced Illness Management program. Additionally, you will have access to a 24/7 tele-support service and can speak with an RN in the event that you should have an urgent issue or need immediate assistance.
Our service begins with an initial assessment conducted in your home by an RN case manager. During this initial meeting, we will try to better understand your illness, your goals, identify any symptoms that are giving you a problem, and the level of support you have from your family, friends and caregivers. Based on this information, we will work with you and your primary physician to develop a plan of care that is focused on your specific needs and goals.
Our clinical team will then walk with you through the course of your illness, helping to ensure that your needs are met and your goals are achieved. We’ll be available to come to your home on a regularly scheduled basis or in the middle of the night if you need to call us in the event of a crisis. Although each care plan is different, most of our care plans include:
• Symptom and pain management
• Disease management
• Medication assistance
• Coordination with the primary physician professional
• Communication with family members and caregivers
• Assistance with light home care and support services
• 24/7 support in the event of a crisis
The circumstances surrounding your needs will likely change over time. As they do, we will be there at any hour of the day or night to provide you the care you need and to recommend any appropriate changes to your care plan. Together, our team will work with you to ensure you achieve your goals and receive the best possible care.