DIABETES PATIENT SELF-CARE WORKBOOK

MY PERSONAL PLAN:

I would like to work on the following areas to manage my diabetes:

Taking My Medicine

Regular Exercise Foot Care

Eating Healthy Other

My GOAL for the next month is:

Possible problems in meeting my goal:

Things that would help me meet my goal:

This material prepared by OASIS Answers, Inc. (www.oasisanswers.com), and is provided by the West Virginia Medical Institute, Inc. the Quality Improvement Organization supporting the Home Health Quality Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number: 9SOW-WV-HH-BBK-012711J App. 01/11.

HEART FAILURE (HF) SELF-CARE WORKBOOK

Take this booklet with you to your doctor appointment

What does Heart Failure mean?

• It means that your heart does not pump enough blood to meet your body’s needs.

• Blood can “back up” in your lungs.

• Too much blood in your lungs causes shortness of breath.

• You may cough more or wake up at night short of breath.

• Blood can also “back up” in other parts of your body.

• You may have swelling in your legs and feet or in your abdomen.

• You may also feel tired and not feel like eating.

Heart failure can be managed

This booklet was put together to help you understand your role (“self-care”) in keeping your heart failure under control.

Self-care includes:

1. Taking your medicines as ordered by your doctor

2. Decreasing the amount of sodium in your diet

3. Avoiding alcohol

4. Exercising and staying active

5. Checking your weight daily and taking action right away when your weight goes up

6. Monitoring yourself for symptoms and taking action right away when they occur

7. Seeing your doctor regularly

Understanding your symptoms

• It is important to understand the symptoms that you have when your heart failure worsens.

• You will tend to have the same symptoms each time your heart failure worsens.

Symptoms I have had are:

HEART FAILURE (HF) SELF-CARE WORKBOOK

Medicines:

• There are 4 types of medicines that are usually used to manage heart failure.

• You may be on more medicines than these.

• Your doctor, nurse, or pharmacist will give you more specific information about your medicine.

• Always check before taking over-the-counter medicine or herbal supplements.

• Some medicine can be harmful for patients with heart failure.

• Your home care nurse will work with you to make sure you understand all of your medicines.

• If you often forget to take your medicine, your nurse can show you different ways to help you remember to take your medicine at the right times.

HEART FAILURE MEDICINES:

Diuretics (“water pills”)

These drugs work in your kidney and help you get rid of extra fluid and sodium through your urine.

I am taking:

Angiotensin converting enzyme (ACE) inhibitor

These drugs work to open up blood vessels. This makes it easier for your heart to pump. Blood pressure is lowered. Use of ACE inhibitors for heart failure contributes to a longer, healthier life. Someone who cannot tolerate an ACE inhibitor may be prescribed an Angiotensin II Receptor Blockers (ARBs) instead.

I am taking:

Beta blockers

These drugs work to improve heart muscle function and block chemicals that can make your heart failure worsen. Blood pressure is lowered. Use of beta blockers in heart failure contributes to a longer, healthier life.

I am taking:

Digoxin

Digoxin makes your heart beat stronger and at a regular rhythm and helps to reduce heart failure symptoms. Your nurse will teach you to check your pulse when you are on Digoxin. Call if your pulse is less than

I am taking:

HEART FAILURE (HF) SELF-CARE WORKBOOK

Diet & Nutrition:

• Sodium makes your body retain fluid.

• Too much fluid makes your heart work harder and can make your heart failure worse.

• Your weight will increase and you may develop symptoms.

• Try to keep your sodium intake about 2000 milligrams (mg) per day or as ordered by your doctor.

• Salt is a major source of sodium. One teaspoon of salt contains 2400 mg of sodium!

• Your nurse or a dietitian will help you look at your own diet, help you read food labels, and can give you lists of foods that are high and low in sodium.

• Avoid alcohol as it can make your heart failure worsen.

• Some patients with heart failure should limit the amount of liquids they drink. Ask your doctor or nurse about this.

I should limit my liquids to:

How can I lower my sodium intake?

Check off the things you think you can do.

� Do not add salt to my foods during cooking.

� Take the salt shaker off of my kitchen table.

� Try other seasonings to add flavor such as lemon juice, onion or garlic powder, or herbs.

� Read food labels to see which foods are high in sodium.

I will avoid high sodium foods such as:

� Canned soups and vegetables

� Hot dogs or packaged lunch meats

� Cheese and cheese spreads

� Deli meats such as ham

� Ketchup, soy sauce, salad dressings, barbeque sauce

� Frozen dinners that are high in sodium

I will eat lower sodium foods more often such as:

� Lean meats

� Low fat milk

� Reduced sodium cheese

� Cereals low in sodium

� Fresh fruits and vegetables

When going out to eat, I will:

� Choose items that are listed as “healthy choice” or “low sodium” on the menu

� Choose broiled or grilled foods instead of fried foods

� Ask for sauces and salad dressings “on the side”

HEART FAILURE (HF) SELF-CARE WORKBOOK

Staying Active and Safe:

• Exercise provides many benefits for you when you have heart failure.

• Activities such as walking, bike riding, or swimming are good exercise options.

• Exercise will:

• Improve your muscle tone

• Strengthen your heart

• Increase your energy

• Make you feel better

• Before starting an exercise program, your heart failure should be stable.

• Your weight should be at baseline and you should not be experiencing symptoms.

• It is important to start slowly when you are not used to exercising.

• A home physical therapist can help you begin your exercise program.

You should monitor yourself for fatigue and shortness of breath when you exercise. Your home care nurse or therapist will teach you how to use the Borg scale so that you can rate your shortness of breath and/or fatigue during activity and exercise.

Modified Borg Scale

0 No breathlessness/fatigue at all

1 Very Slight Breathlessness/Fatigue

2 Slight Breathlessness/Fatigue

3 Moderate Breathlessness/Fatigue

4

Somewhat Severe Breathlessness/Fatigue

HEART FAILURE (HF) SELF-CARE WORKBOOK

Telehealth Strategies...

In addition to seeing you in your home, your home care nurse may also suggest or use “telehealth” to monitor your heart failure.

What is telehealth ?

1. Your home care nurse calls you on the phone – simple telephone monitoring. You will be asked questions about your daily weights or if you are having symptoms. Your nurse will review information you need to know to better manage your heart failure.

Example Question: “Are you having any increased swelling?”

2. Telemonitoring

A monitoring system is placed in your home. This may include a special scale, blood pressure cuff, and other device(s). The monitor may also include questions on a computer that you answer each day. Some systems include computer screens where you and your nurse can see each other while you talk. Your nurse will teach you how to use the telemonitoring system. Your information (weight, blood pressure, etc.) is sent to the home care agency computer, usually over the telephone lines. A nurse at the agency checks your information every day. If there are changes, your nurse will call you or visit you at home.

3. You call the home care agency

Your weight may be up or you are having symptoms. You may just want to ask a question.

Example Question: “I feel out of breath, even when I’m resting! What should I do?”

The home care nurse may give you advice over the telephone, may want to see you at your home to check your condition, or may tell you to call 911 if your symptoms are severe.

MANAGING YOUR CONDITION Sudden weight gain

A sudden increase in weight means that your body is retaining fluid. If your weight goes up, this is the time to TAKE ACTION. Do not wait for other symptoms to occur. An extra diuretic pill for a day or two is usually prescribed until your weight comes back down.

Action taken right away will help keep you out of the hospital.

If you do have a weight gain, think about possible reasons why?

• Did I forget to take my medicine?

• Did I eat high sodium foods in the last few days?

HEART FAILURE (HF) SELF-CARE WORKBOOK

DAILY WEIGHT LOG

Record your weight each day: same scale, same time of day, same type of clothing.

REPORT! Weight gain of or more pounds within a day period

YOUR ACTION PLAN:

Use this guide to help you report changes in your symptoms to your doctor or home care provider. Reporting symptoms early may keep you out of the hospital.

You are doing WELL when:

• Your weight is stable

• You have no trouble breathing

• You can do your normal activities

• You have no changes in your symptoms

Call in the next 24 hours when:

• Your weight goes up pounds in days

• You have new swelling in your feet, ankles, hands, or abdomen

• You have a dry, harsh cough that does not go away

• You use 2 or more pillows or a recliner to breathe better at night if this is different from how you usually sleep

• You feel more tired or have less energy than usual

• You have side effects from your medicines

Call your doctor RIGHT AWAY when:

• You have trouble breathing –

• Call 911 for severe shortness of breath

• You feel dizzy

• You feel very anxious

• Call 911 if you have chest pain that does not go away

HEART FAILURE (HF) SELF-CARE WORKBOOK

I would like to work on the following areas to manage my heart failure:

My GOAL for the next month is:

Possible problems in meeting my goal:

Things that would help me meet my goal:

This material prepared by OASIS Answers, Inc. (www.oasisanswers.com), and is provided by the West Virginia Medical Institute, Inc. the Quality Improvement Organization supporting the Home Health Quality Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number: 9SOW-WV-HH-BBK-012711M App.

Home Environment Safety Evaluation

Check Yes or No for each of the following items. For all “No” responses, identify in the space provided the item number and the action plan to correct the problem. All 18 items are applicable to every patient and should be answered.

Yes Enhancing the Quality of Life at Home TM TOLL FREE : 1-877-LORIAN-5 (1-877-567-4265) www.lorianhealth.com

1. There is a working telephone and emergency number accessible

2. Electric cords and outlets appear to be in good repair in the patient area

3. There is a functional smoke alarm

4. Fire extinguisher is available and accessible

5. Access to outside exits is free of obstruction

6. Alternative exits are accessible in case of a fire

7. Walking pathways are level, uncluttered, and have non-skid surfaces

8. Stairs are in good repair, well lit, uncluttered, have non-skid surfaces, or there are no stairs

9. Lighting is adequate for safe ambulation and ADL

10. Handrails are present if applicable

11. Temperature/ ventilation is adequate

12. Poisonous/ toxic substances are clearly labeled and placed where client can reach, as needed, but not within reach of children

13. Bathroom is safe for provision of care

14. Oxygen safety a. Are there smoking materials in the home b. Are there oxygen alert signs in place c. Are there potential risks for open flames d. Are there emergency backup tanks available

15. Overall environment is sanitary for provision of care

16. An emergency preparedness plan is in place and has been discussed

# Action Plan Pt verbalized understanding of corrections suggested

Additional Comments:

A MEDICARE-CERTIFIED HOME HEALTH AGENCY Serving California and Nevada Documents 51

Clarification Of Homebound Status

For a patient to be eligible to receive covered Home Health services, Medicare requires that a physician certifies in all cases that the patient is homebound, i.e. the patient is confined to his or her home. To be considered homebound, there must be a normal inability to leave the home, or leaving the home would require a considerable and taxing effort on the part of the patient, or would be a risk factor to the patient.

The patient’s absence from home may be considered evidence that the patient is not homebound except under the following circumstances:

Any absence attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in a licensed or certified adult day-care program.

Any absence for the purpose of attending a religious service.

Any other absence that is infrequent or of a relatively short duration.

Your homebound status will be reflected and documented frequently in the medical record.

By signing the Patient Service Agreement on page 53, you are acknowledging your understanding of the Medicare requirements and regulations regarding “homebound status”.

If Medicare is not providing payment for your home health services, then you are not required to meet homebound criteria.

FREE : 1-877-LORIAN-5 (1-877-567-4265)

Procedure For Requests And Complaints

Lorian Health (Lorian) wants to provide you the best possible service. For that reason, in the event that you are unhappy with anything having to do with our delivery of your care, please do not hesitate to notify Lorian directly at (877) 567-4265. We appreciate the opportunity to improve our service, deliver you better care, and resolve any complaints you may have. There will be no ill effects or repercussions to you involving your complaint or request for any change in service provider, or in response to any other reasonable request you may have that would result in your improved satisfaction with our care delivery.

In the event we are unable to satisfy your needs and you feel you would like to file a formal complaint with Lorian’s supervising entity, there is a licensing body available to you 24 hours a day, 7 days a week that you may call toll free to report your complaint. Below is the following information relating to that licensing body:

For Lorian Health San Diego County

California Department of Public Health, Licensing and Certification, Northern San Diego District, 7575 Metropolitan Drive, Suite 104, San Diego, CA 92103

Make confidential complaints, including complaints concerning advanced directives, to the California Department of Public Health, Licensing and Certification Division without being subject to discrimination or reprisal. The home health hotline number for registering a complaint is (800) 824-0613, and it may be used 24 hours per day, 7 days a week.

For Lorian Health Orange County and Riverside County

JCAHO: available 8½ hours a day 5 days a week (Central time) that you may call toll free to report your complaint. Office of Quality Monitoring, The Joint Commission One Renaissance Boulevard, Oakbrook Terrace, Illinois 60181 and the e-mail address is complaint@jointcommission.org.

Make confidential complaints, including complaints concerning advanced directives, to the Office of Quality Monitoring, Joint Commission without being subject to discrimination or reprisal. The home health hotline number for registering a complaint is (800) 994-6110, and it may be used from 8:30 am to 5:00 pm Monday through Friday Central time. The fax number is (630) 792-5636.

Riverside County: You may also contact California Department of Public Health 7 days a week/24 hours a day without being subject to discrimination or reprisal. The mailing address is 625 E. Carnegie Dr., Suite 280, San Bernardino, CA 92408 and the home health hotline number for registering a complaint is (888) 354-9203.

Orange County: You may also contact California Department of Public Health from 8:00 am to 5:00 pm Monday through Friday without being subject to discrimination or reprisal. The mailing address is 681 S. Parker Street, Suite 200, Orange, CA 92868 and the home health hotline number for registering a complaint is (800) 228-5234.

For Lorian Health San Bernardino County

California Department of Public Health, Licensing and Certification, 464 West Fourth Street, Suite 529, San Bernardino, CA 92401

Make confidential complaints, including complaints concerning advanced directives, to the California Department of Public Health, Licensing and Certification Division without being subject to discrimination or reprisal. The home health hotline number for registering a complaint is (800) 344-2896.

For Lorian Health Los Angeles County

California Department of Public Health, Licensing and Certification, 12440 E. Imperial Highway, Room 522, Norwalk, CA 90650

Make confidential complaints, including complaints concerning advanced directives, to the California Department of Public Health, Licensing and Certification Division without being subject to discrimination or reprisal. The home health hotline number for registering a complaint is (800) 228-1019.

For Lorian Health Clark County

Department of Health and Human Services, Bureau of Health Care Quality & Compliance, Southern Nevada District Office, 4420 South Maryland Parkway, Suite 810, Las Vegas, Nevada 89119

Make confidential complaints, including complaints concerning advanced directives, to the State Department of Health and Human Services Licensing and Certification Division without being subject to discrimination or reprisal. The home health hotline number for registering a complaint is (800) 225-3414, and it may be used 24 hours per day, 7 days a week.

For Lorian Health San Jose

California Department of Public Health San Jose District Office100 Paseo de San Antonio, Suite 235 San Jose, CA 95113. Phone Number: (408)277-1784

Photo Consent Form

The undersigned does hereby authorize

Lorian Health

and/or its associates, assistants to photograph

Name (please print):

The undersigned authorizes Lorian Health to permit the use and display of said photographs for the purpose of providing information to physicians, medical institutions and constituent departments.

The undersigned agrees that Lorian Health may use name, likeness or biographical information supplied by the undersigned.

The undersigned releases and forever discharges Lorian Health, its agents, officers and employees from any and all claims and demands arising out of or in connection with the use of said photographs / images, including but not limited to, and claims for invasion of privacy or defamation.

Accepted and Agreed:

Patient Signature Date