Chronic Disease Management

We recognize the significant gap that patients with chronic diseases face when they transition from a hospital or facility.  Their conditions and medications are closely monitored and dispensed at regular intervals right up until discharge. Once the patient arrives home they become solely responsible for managing their condition.  Natick VNA’s integrated care approach focus on empowering patients to managing their illness utilizing state of the art monitoring equipment, treatment coordination and  a clear focus on patient and caregiver education. 

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Comprehensive Wound Care

Natick VNA board certified, wound specialists work collaboratively with physicians, wound clinics and hospitals to provide advanced wound care treatments for acute and chronic wounds. Our team focuses on specialized treatment plans that include specific protocols, nutrition, environment, patient and caregiver education, and prevention.  Our goal is always to improve the quality of life of our patients and caregivers.

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Post Hospital Care

Patients are often confused about the discharge instructions set out by their care providers. Most elderly patients are contending with multiple chronic diseases/conditions and medications. They are often readmitted for an adverse event within 30 days of discharge because they do not understand or did not follow instructions given to them. If there is no care coordination across settings, there is often conflicting and confusing information in the Care Plan or discharge instructions from different provider settings. Our Care Transition Coordinators collaborate closely with discharge planners, care managers and patients to ensure a smooth transition for patients.

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Care Transitions

An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your health care costs if you have a chronic disease by preventing or minimizing the effects of a disease.

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Telehealth gives care teams the capability to monitor and coach high risk, chronic patients helping them improve their ability to manage their own condition. Care plans are tailored for the unique needs of each patient, delivering a personalized experience for patients. The Natick VNA’s telemonitoring system monitors patients’ blood pressure, pulse, weight, and blood oxygen levels enabling clinicians to make timelier care decisions.

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