Chronic Condition Management

Use this screening tool to evaluate patients with heart failure, COPD, and/or diabetes. Click the button to show the relevant questions for each condition and then ask the patient about the symptoms, as appropriate. 

 

Shortness of breath
Worsening swelling anywhere
Chest pain at any time
Wheezing
Chest tightness
Increased mucus production
Blood sugar levels and effects over past few days

Documentation

The patient is reporting the following symptoms:

  • No symptoms reported
  • Leg edema
  • Weakness
  • Angina
  • Orthostasis
  • Dyspnea on exertion
  • Paroxysmal nocturnal dyspnea
  • Fatigue
  • Shortness of breath
  • Persistent cough
  • Ascites
  • Difficulty concentrating
  • Chest pain
  • Other (please specify)

Note the status of reported symptoms: stable, worsening, unstable, unable to assess

 

Patient's disposition:

  • Patient remained at home without urgent escalation — provider informed
  • NCC informed of acute symptoms
  • NCC informed of recommendation for urgent care/activation of community paramedicine
  • 911 contacted (life threatening signs and symptoms
  • Other (please specify)

 

Interventions:

  • Instructed patient/caregiver on importance of monitoring daily weights to prevent symptom exacerbation
  • Reviewed the need to report a weight gain of greater than 2lbs in one day or 5lbs in one week to the appropriate provider
  • Instructed patient/caregiver to perform daily weights in the morning using the same scale, after urinating and before eating or drinking
  • Instructed patient/caregiver to record daily weights in log book
  • Other (please specify)

 

Weight assessment: record patient's reported weight and weight in the past 7 days (range) to assess:

  • No change
  • Weight gain of > 2 lbs in one day or 5 lbs in one week
  • Weight gain of < 2 lbs in one day or 5 lbs in one week
  • Weight loss < 2 lbs in one day or 5 lbs in one week
  • Weight loss > 2 lbs in one day or 5 lbs in one week

 

Heart failure medication regimen:

  • ACE inhibitor, ARB, ARNI
  • Beta-blocker
  • Aldosterone antagonist
  • Standing diuretic
  • PRN diuretic / water pill
  • Digoxin
  • Other (please specify)

Confirm patient has adequate medication supply and 90-day refills

  • If not, are they willing to switch to 90-day refills?
    Coordinate with prescribing MD
  • In agreement for home delivery?
    Inquire with listed pharmacy if this is an option

The patient is reporting the following symptoms:

  • No symptoms reported
  • Shortness of breath with exertion
  • Shortness of breath at rest
  • Wheezing
  • Chest tightness
  • Increased mucus production
  • Cough
  • Cyanosis
  • Fatigue
  • Somnolence
  • Unintentional weight loss
  • Night sweats
  • Fever and chills
  • Other (please specify)

Note the status of reported symptoms: stable, improving, worsening (consult NCC), unable to assess

Escalated to NCC?Yes/No

 

Access to COPD medications:

  • Patient has all prescribed medications and reports no difficulty with obtaining refills
  • Patient does have all prescribed medications but reports concerns about obtaining refills
  • Patient does not have all prescribed medications

 

Barriers to obtaining COPD medications:

  • Patient reports difficulty with affording medications
  • Patient reports difficulty with obtaining new prescriptions from provider
  • Patient report difficulty with physically obtaining medications from pharmacy
  • Other (please specify)

 

Intervention relating to COPD medications:

  • Informed NCC of SW referral to address financial/physical barriers to obtaining medications
  • Informed prescribing provider regarding need for new prescriptions (advocate for 90-day supply)
  • Requested care coordinator assistance with scheduling appointment with prescribing provider
  • Contacted pharmacy to confirm active prescriptions/refills (opt for home delivery)
  • Contacted pharmacy to arrange home delivery of medications
  • Other (please specify)

 

Current medication regimen:

  • Metered Dose Inhaler (MDI) with spacer
  • Dry powder inhaler (DPI)
  • Respimat inhaler
  • Nebulizer treatments
  • PO medications
  • Rescue Pack
  • Steroid treatment
  • Antibiotic

Confirm patient has adequate medication supply and 90-day refills

  • If not, are they willing to switch to 90-day refills?
    Coordinate with prescribing MD
  • In agreement for home delivery?
    Inquire with listed pharmacy if this is an option

The patient is reporting the following symptoms:

Hypoglycemia symptoms:

  • No symptoms reported
  • Confusion
  • Dizziness
  • Headaches
  • Hunger
  • Mood changes
  • Pallor
  • Seizures
  • Sleepiness
  • Speech difficulty
  • Sweats
  • Tremors
  • Other (please specify)

Hyperglycemia symptoms:

  • No symptoms reported
  • Confusion
  • Dizziness
  • Headaches
  • Hunger\thirst
  • Mood changes
  • Nervousness\anxiety
  • Pallor
  • Seizures
  • Sleepiness
  • Speech difficulty
  • Sweats
  • Tremors
  • Other (please specify)

Note the status of reported symptoms: stable, improving, worsening (consult NCC), unable to assess

Record blood glucose reading today and in the last 3 days. Inform NCC if reading is less than 60 mg/dl or more than 250 mg/dl.

Escalated to NCC? Yes/No

 

Insulin regimen: (name of med)

  • Dose schedule
  • Pre-breakfast
  • Pre-lunch
  • Pre-dinner
  • Bedtime
  • Given by
  • Patient
  • Adult caretaker
  • Friend
  • Grandparent
  • Nursing attendant
  • Parent
  • Relative/sibling
  • Significant other

Confirm patient has adequate medication supply and 90-day refills

  • If not, are they willing to switch to 90-day refills?
    Coordinate with prescribing MD
  • In agreement for home delivery?
    Inquire with listed pharmacy if this is an option
  • Refer to clinical providers (specialist, clinical pharmacist, primary care)
  • Schedule in-person or virtual visit (if possible)
  • Will you be able to attend or get this appointment?