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Chronic Care Programs | RightPath®

We understand that living with a chronic medical condition (cancer, COPD, diabetes, heart failure (CHF) etc.) can be challenging and overwhelming at times. With the AccentCare, proprietary RightPath programs we can focus on your unique needs to help manage your condition, while optimizing your health and independence, wherever you call home.

RightPath programs use expert clinical guidelines and evidence-based practices that complement your physician’s orders. And our patient outcomes rank above national averages for many measures, including lower unplanned re-hospitalization rates.

  • Patients with congestive heart failure (CHF) often suffer from symptoms that interfere with daily life, such as shortness of breath, fatigue and weakness. Our RightPath® CHF program may help improve these symptoms so that patients are able to live more comfortably while managing their condition.
  • For CHF Medicare patients, our program reports an 18% unplanned re-hospitalization rate versus the average (26%) as measured by Stone and Hoffman. In fact, AccentCare patients show improvement in breathing and improvement in ambulation for a higher percentage of patients than the average for all home health companies.
  • Our Cardiac Program includes:
    • Clinical pathways for congestive heart failure and heart disease
    • Peak flow testing and action planning for reactive airway conditions
    • Individualized care plans
    • An interdisciplinary team approach including skilled nursing, physical and occupational therapy and other disciplines
    • Telemonitoring
    • Care transition and coordination support
    • Patient and family education on medication, nutrition and self-management
  • Living with COPD (Chronic Obstructive Pulmonary Disease) can require daily management. Our RightPath® COPD program can help manage symptoms and improve ambulation.
  • As measured by Strategic Health Programs (SHP), 75% of patients in our program show improvement in breathing versus the average of all home health companies (68%). In addition, AccentCare reports improved ambulation and lower unplanned re-hospitalization rates for COPD patients that exceed national averages.
  • Our COPD program includes:
    • Clinical Pathway specific to COPD management
    • Peak flow testing and action planning for reactive airway conditions
    • Medication management
    • Individualized care plans
    • An interdisciplinary team approach including skilled nursing, physical and occupational therapy and other disciplines
    • Telemonitoring
    • Care transition and coordination support
    • Patient and family education on medication, nutrition and self-management
  • We understand that diabetes requires constant monitoring and management. Diabetes can often lead to other medical conditions such as hypertension and COPD, which are leading causes for re-hospitalization.
  • Our RightPath® Diabetes program reports unplanned re-hospitalization and emergent care hospitalization rates that are below the national average of home health companies as measured by Strategic Health Programs (SHP).
  • We monitor symptoms while maintaining compliance with disease management principles to help ensure diabetic patients have optimal outcomes.
  • Our diabetes program includes:
    • Prevention, detection and treatment of complications
    • Clinical Pathways specific to Diabetes Management
    • Medication management
    • Individualized care plans
    • An interdisciplinary team approach including skilled nursing, physical and occupational therapy and other disciplines
    • Telemonitoring
    • Care transition and coordination support
    • Patient and family education on medication, nutrition and self-management
  • For patients who have recently undergone joint replacement, AccentCare has developed the RightPath® Program for Joint Rehabilitation to help address their specific postoperative needs.
  • This program has reported improved outcomes for a higher percentage of patients than the national average of home health companies as measured by Strategic Health Programs (SHP). These outcomes include pain reduction, improved ambulation, improved status of surgical wounds and decreased unplanned re-hospitalization rates.
  • As measured by Strategic Health Programs (SHP), 81% of patients in our program report pain reduction versus the average of all home health companies (76%). In addition, AccentCare reports improved status of surgical wounds, improved ambulation and lower unplanned re-hospitalization rates for at a higher percentage of joint rehabilitation patients than the national average for all home health companies.
  • The program includes:
    • Surgical wound management
    • Pain management
    • Medication management
    • Patient and family education on safety, balance and exercise
    • Individualized care plans focused on therapeutic intervention
    • An interdisciplinary team approach including skilled nursing, physical and occupational therapy and other disciplines
    • Telemonitoring
    • Care transition and coordination support
  • Caring for a loved one who is showing signs of depression can be difficult for families and caregivers. Despite the prevalence of late-life depression among seniors, it is a condition that often goes undiagnosed. Symptoms of late-life depression including changes in weight, tearfulness or increased sadness, apathy toward previously enjoyed activities, increased anxiety, increased confusion and misuse of pain or anxiety medication.
  • Our RightPath® Late Life Depression program has helped to reduce symptoms of depression and anxiety for more than 84% of our patients.
  • The program includes:
    • Experienced Behavioral Health Nurses who specialize in depression management
    • Medication management
    • Individualized care plans
    • An interdisciplinary team approach including skilled nursing, physical and occupational therapy and other disciplines
    • Telemonitoring
    • Care transition and coordination support
    • Patient and family education on medication and self-management strategies
    • Ongoing communication with the patient, their physician and their loved ones
  • Palliative care is specialty care for individuals living with a chronic illness, focused on relief from pain and symptoms while supporting emotional and social well-being. If you or a loved one has an advanced chronic illness such as heart failure, cancer, diabetes or COPD, you may benefit from palliative care at home. Our RightPath® Palliative Care program blends curative and comfort treatments to meet the individual’s goals of care. The program includes:
    • Comfort of the mind and body through active pain/symptom management, emotional and spiritual support
    • Advanced care planning to assist you in developing your goals for care and choices for treatment
    • Individualized care plans to address physical, emotional and spiritual needs based on your personal wishes
    • Patient and family education to enable you to participate in your self-care and make the best lifestyle choices to optimize day-to-day health
    • Medication management
    • Telemonitoring
    • Care coordination to support changing priorities and needs during care transitions

Home Health Technology

We have dedicated Telehealth Team to support remote care.

  • Virtual visits, via an exclusive video platform partnership with Synzi
  • Telemonitoring devices for near real-time data to identify changes in patient condition

Patient Benefits

  • Reduce exposure/spread of COVID-19
  • Reduce hospitalization
  • Reduce emergency department utilization
  • Secure, HIPPA-compliant platform
  • Increases capacity for patient visits, by more effectively deploying home health resources

How it Works

  • Physician orders home health for patient
  • Accepted patient receives welcome call
    • Introduces and explains home care
    • Validates information (including presence of smart devices
  • Nurse makes initial home visit
    • Conducts routine assessment
    • Develops plan of care
  • Nurse evaluates applicability of supporting technology
    • Determines need for telemonitoring
    • Screens for most appropriate option
    • Orders appropriate device
  • Determines if patient could benefit from virtual visits

Patient Qualifications 

  • Physician order for AccentCare home health services
  • Smart device already in the home such as phone, tablet (Apple iPad, Samsung, Chrome), or laptop computer with camera
  • Physician agreement to include virtual visits in plan of care
  • Willing participation (patient and/or caregiver)

Patient Qualifications 

  • Physician order for AccentCare home health services
  • Smart device already in the home such as phone, tablet (Apple iPad, Samsung, Chrome), or laptop computer with camera
  • Physician agreement to include virtual visits in plan of care
  • Willing participation (patient and/or caregiver)

How It Work

  • Patients will receive in-person guidance from a trained home health nurse at, or shortly after, start of care.
    • Initial home visit to conduct assessment and develop plan of care
    • Set-up assistance for patient and/or family caregiver
    • Download Synzi app onto smart device in the home
      • Log in to register with date of birth (HIPAA-compliant)
      • To participate in a home visit, simply accept the video call
    • Reminder to call our local office with any questions or future needs regarding the app
  • Physicians can virtually participate in home health visits.
    • AccentCare case manager can schedule with physician in advance
    • At start of scheduled visit, link sent to physician for merged video call

Supplementing Quality Home Care for At-Risk Patients

We supplement clinician home visits with telemonitoring for remote clinical observation to discern change in condition and enable timely changes in care plans.

We have partnered with Medtronic, a leader in the creation and supply of medical devices, to enable the collection of near real-time biometric data to:

  • Help decrease risk of exposure
  • Support quality outcomes
  • Reassure patients who may feel insecure about their health

Patient Qualifications 

  • Unstable or new condition
  • At-risk for re-hospitalization or emergency room visit
  • Concern for COVID-19 exposure
  • Absence of cognitive or relevant physical impairment for patient and/or caregiver
  • Safe home environment
  • AccentCare home health patient for a minimum 2-week plan of care
  • Physician and patient willingness

Patient Benefits

  • Increases frequency of valuations
  • Reduce exposure/spread of COVID-19
  • Reduce re-hospitalization rates
  • Reduce emergency department utilization
  • Reduce patient anxiety due to uncertainty about their health and fear of exposure

How It Works 

Following our initial home visit, the patient receives in-person guidance from a specially trained home health nurse.

  • Nurse identifies the device best suited to capture patient’s biometric data such as:
    • Blood pressure – Blood glucose – Pulse – Weight – SPO2
  • Shipment is tracked for notification of arrival
  • Telenurse calls patient and/or caregiver to explain how to set up device
  • Dedicated Telehealth Team provides support
    • Physician-established patient-specific parameters programmed into device
    • Data received and reviewed daily
    • Remote problem-solving when feasible (e.g., change in medication, weight gain)
    • Dispatch of nurse or initiation of virtual visit when needed
  • Custom reports available upon physician request
Available in Minnesota ONLY at this time

Offers a variety of home safety and medication management devices, along with professional installation, guided instruction, and customer support.

Available in Pennsylvania and Virginia ONLY at this time

SE Connect is a one-button device, which can be carried anywhere by the patient, that automatically connects you and caregivers to the Care Center within 45 seconds.

The Call Center addresses emergency and non-emergency issues, and serves as a personal concierge and GPS tracker. In the event of a fall or other medical emergency, the operator accesses the person’s call protocol and contacts the appropriate individual(s). This may be 911, a family member, or perhaps AccentCare, if that is listed on the call protocol.

With remote monitoring technology, patients can provide their medical professionals with updated vital signs with easy-to-use medical devices. The AccentCare team will work with the patient to ensure that the device(s) is set up, connected and that the patient is comfortable using it.

Patient Benefits

  • Easily send vital signs, alerts, and reports for real-time monitoring
  • Have live video conferencing with their medical professionals
  • Include family members in video consultations

How It Works

  • Using Bluetooth-enabled remote patient monitoring devices to collect biometric data in real-time
  • Pairing a 4G tablet (provided) to automatically capture and transmits data to AccentCare Southeastern Health Care at Home’s HIPAA-compliant Wellness Management Services (WMS) portal
  • Enabling 24/7 access to data, automated alerts, and reminders to healthcare professionals, caregivers, and patients

Bluetooth-Enabled Devices

  • 4G tablet
  • Scale
  • Blood Pressure Machine
  • Pulse Oximetry
  • Spirometer

Our Services

Questions? Please use the site Chat feature for your convenience OR call (800) 834-3059.