Chronic Care

Home Care for Chronically Ill Patients
Dedicated solely to serving chronically ill Medicare patients in the comfort of their own homes.

The Visiting Nurse Association of Greater Philadelphia continues its historic mission of meeting the evolving health care needs of our community with Home Care for Chronically Ill older adults. Our dedicated team of Registered Nurses and Advanced Practice Nurses with diagnostic and prescriptive capabilities will evaluate and manage -- on a long-term basis -- chronically ill older adults who have multiple medical and social needs. These chronic care patients may have illnesses such as chronic renal failure, congestive heart failure, arthritis, cancer and other conditions. Care is an active process. We work closely with all the patient’s service providers – family, social services and others – to ensure that the patient’s care is well coordinated while promoting medical safety and/or recovery.

Older adults who are homebound with more than one of the following conditions may be considered for a Chronic Care patient assessment:

• Multiple/long term medical problems
• Multiple medications
• Multiple functional limitations
• Deficits in Activities of Daily Living (ADLs)
• Health risking behaviors such as drug abuse, alcoholism
• Deficits in support systems, such as abuse or unsafe environment.
• Difficulty obtaining community resources
• Multiple community resources needed
• Nutritional/hydration problems
• History of frequent hospital admissions or emergency room visits

The Registered Nurse provides a comprehensive assessment (holistic) of the patient’s condition including the physical, mental, nutritional, emotional, social, environmental or financial support systems and manages interventions and evaluates results of interventions to promote patient recovery and medical safety.

Payment for Services

This program is available to all Medicare eligible clients who meet the criteria.