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Disease State Management

Grane Home Health Care offers comprehensive disease state management programs for chronic respiratory and cardiac illnesses, diabetes, and orthopedic-related disease processes such as arthritis, frequent falls, and stroke-related limitations. The disease state management programs incorporate an interdisciplinary approach to chronic disease that focuses on your holistic care and life adaptations. You will be assigned a registered nurse case manager to manage communications among your providers, provide patient and caregiver education, and communicate regularly with insurers. Each program is specific to the chronic disease that needs to be cared for.
Chronic Obstructive Pulmonary Disease, Pneumonia

  • Collaboration with primary care physician and pulmonary
  • Development and implementation of your specific plan of care and schedule
  • Medication management
  • Respiratory treatments as ordered by physician, including oxygen management
  • Energy conservation as you live your life
  • Coordination of other therapeutic disciplines such as therapy and/or nutritional services
  • Education for you and your caregiver including symptoms requiring physician follow up

Congestive Heart Failure

  • Communication to your primary care physician and cardiac specialists
  • Medication management including respiratory care as ordered
  • Rehabilitative and restorative care including physical and occupational therapy
  • Individualized plan of care including energy conservation techniques
  • Education for you and your caregiver from experts in involved disciplines
  • Coordination of care by your RN case manager


  • Collaboration with your primary care physician, family, caregivers, and any specialists
  • Medication management and blood glucose stabilization
  • Education for you and your family regarding medications, blood glucose monitoring, and diet
  • Glucometers if you have visual or hearing impairment
  • Individualized and specific care plan and schedule development by you and your RN case manager in collaboration with your physicians, family, and caregivers
  • Treatments such as wound management, oxygen therapy, and smoking cessation as appropriate
  • Ongoing communication between RN case manager and primary care physicians or specialists

Arthritis, Degenerative Joints, Frequent Falls

  • Assessment and evaluation by RN case manager and follow-up consultation with primary care physician, orthopedic surgeon, and other specialists
  • Functional evaluations by physical therapist and occupational therapist
  • Environmental assessment by RN case manager and therapist to decrease risks of environmental hazards
  • Medication management
  • Coordination of equipment needs as recommended by therapist and RN case manager
  • Energy conservation with individualized plan of care and schedule for daily activities
  • Strengthening and exercise program developed specifically for you by therapy specialists

Patient success, evidenced by decreased hospitalizations, length of stay, or resource utilization, is dependent on effective communication between you, your RN case manager, the Grane professionals who are part of your specific health care team, and our partners in the community. Grane recognizes that you and your family always have a choice when it comes to choosing a service. Grane Home Health Care is committed to effective communication with community partners as well as those within the Grane family.
Restoring Health
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What is Home Health Care?
Learn about Home Health Care, when it should be considered, who pays for it, and how you canĀ initiate in-home services.
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