Managing a serious disease and relief from its symptoms can make all the difference in the quality of your life and in the lives or your loved ones. Our certified Nurse Practitioners can help you along the way.

 

 

Care We Provide

Overview

Advanced Disease Management allows for optimization of symptom control in patients experiencing chronic or terminal medical conditions. This approach encompasses the physical, emotional and spiritual care of each patient.

Care Services

Heartland’s Advanced Disease management team provides consultation services designed to minimize the impact of a patient’s chronic disease state through:

  • Collaborating with the patient’s primary care provider
  • Providing recommendations regarding pain and symptom management
  • Offering patient and caregiver education about their disease and care
  • Assisting patients and caregivers with understanding and communicating complex health care decisions and quality of life

The Advanced Disease Management (ADM) program works in collaboration with your physicians to promote your comfort and well-being. A nurse practitioner from Heartland Care Partners' ADM program will visit you in your place of residence to offer expertise in relieving these and other problems related to your disease:

Cardiac Diseases (heart failure, cardiac dysrhythmias, ischemic heart disease)

  • Shortness of breath
  • Fatigue
  • Nausea
  • Anxiety
  • Depression
  • Swelling
  • Appetite or weight changes
  • Changes in functional abilities
  • Medication side effects
  • Social, emotional and spiritual support
  • Caregiver support
  • Advance care planning discussions—defining the goals of your care

Lung diseases (COPD, pulmonary fibrosis, interstitial lung disease, asthma)

  • Shortness of breath
  • Cough
  • Pain
  • Changes in appetite or weight
  • Recurrent pneumonia
  • Depression
  • Anxiety
  • Changes in sleep patterns
  • Changes in functional abilities
  • Medication side effects
  • Social Isolation
  • Social, emotional, and spiritual support
  • Caregiver support
  • Advanced care planning discussions—helping to define the goals of your care

Neurologic Diseases (stroke, Parkinson’s, ALS, dementia)

  • Falls
  • Agitation
  • Wandering
  • Changes in swallowing function
  • Changes in speech
  • Depression
  • Anxiety
  • Appetite or weight changes
  • Social Isolation
  • Medication side effects
  • Social, emotional, spiritual support
  • Caregiver support
  • Advanced care planning discussions

Cancer

  • Pain
  • Fatigue
  • Anxiety
  • Depression
  • Changes in sleep patterns
  • Weight changes
  • Nausea/vomiting
  • Constipation
  • Diarrhea
  • Side effects of cancer treatment including chemotherapy and radiation
  • Social, emotional, and spiritual support
  • Caregiver support
  • Advanced care planning discussions—helping you to define the goals of your care

Kidney Disease

  • Changes in blood pressure
  • Fatigue
  • Recurrent infections
  • Social isolation
  • Pain
  • Medication side effects
  • Social, emotional, and spiritual support
  • Caregiver support
  • Advanced care planning—helping you to define the goals of your care

How We Work With Our Patients

Leveraging Strengths Across the Continuum

Treatment plans for an advanced or chronic disease often require different perspectives from different medical disciplines. At times, these treatment plans can be complicated and even overwhelming. Our nurse practitioners can help coordinate your treatment, including pain management, emotional health, goal planning and communication.

“Thank you for your support of our client’s daughter. Your calming presence helped her. Thanks for all you do.”

Mary Dubois, LISW-CP, MHA, CCM Palliative Care Social Worker Medical University of South Carolina

Care Settings

Wherever You Call Home, You’ll Find Us.

Heartland Care Partners is uniquely positioned to provide Advanced Disease Management at convenient locations across the country in any number of Heartland ManorCare facilities, or in some cases, at home. The services are administered by nurse practitioners at skilled nursing centers, assisted living centers, memory care communities and at home, and can follow you from one setting to the next across the continuum of care.

Our Markets

14 States, 24 Markets* with Certified Nurse Practitioners Trained in Palliative Care

Heartland Care Partners began in 2011 in Reading, Pennsylvania. Since that time, we have expanded into 24 markets throughout the nation. The program has been so well received, it is expanding rapidly to serve the needs of our patient population.

 

*As of Q1 2017

Allentown, PA

Augusta, GA

Baltimore, MD

Bay City, MI

Butler, MO

Charleston, SC

Cincinnati, OH

Columbus, OH

Detroit Suburbs, MI

Fairfax, VA

Flint, MI

Ft Lauderdale/Boca Raton, FL

Greater Chicago, IL

Green Bay, WI

Indianapolis, IN 

Madison, WI

Miami, FL

Milwaukee, WI

Myrtle Beach, SC

Newark, DE

Oklahoma City, OK

 

Philadelphia, PA

Pittsburgh, PA

Raleigh, NC

Reading, PA

Rockford, IL

Toledo, OH

Warrenton, VA

West Deptford, NJ

We not only help you cope with the day-to-day implications of your disease, we have the multidisciplinary expertise to help understand often complex treatment options, and navigate them successfully.

Your Care Team

Working Together To Deliver The Care You Need.

Your Care Team will consist of yourself, your family, a nurse practitioner and your physician—all focused on education, pain and symptom management, complex health care options, advanced care planning, and coordination of care across the continuum. From time to time your team may included your pharmacist, registered nurses, social workers, dietitians, spiritual care counselors and therapists, as needed.

Patient

When you're facing an advanced disease, you and your family will be faced with a number of critical decisions that will determine the course of your treatment, but you will not do so alone. Your care team will help you understand treatment options.

Family

An advanced disease also affects family members who often find themselves unprepared for their roles as caregivers, and unfamiliar with the effects of the disease. It’s imperative that family members understand treatment options and have a voice in patient care.

Physicians

Your physician wants what is best for your health; this often requires a multidisciplinary approach. Your doctor will be an important part of your care team and is always a part of the critical decision-making process.

Nurse Practitioners

Nurse Practitioners coordinate care for patients with advanced diseases in collaboration with the medical director, attending physician, specialists and nonphysical providers to effectively meet your medical, psychological and spiritual needs.

"I am passionate about providing quality care to all. My goal is to deliver compassion, support and education to patients and their families in a holistic manner through Heartland’s Advanced Disease Management program."

—Pauline, ANP-BC

“Soy más que entusiasmada de aportar su experiencia y comenzar a colaborar con el Equipo de Tratamiento de Enfermedades Avanzadas para ofrecer atención excepcional a los pacientes y a sus familias.”

—Rachel, MSN, FNP-BC

“I believe that chronic illness has an effect on the physical, emotional, mental, and spiritual aspects of an individual. You cannot treat one aspect without treating the other.”

—Candyce, MSN, FNP-BC

Patient Scenarios

Heartland Advanced Disease Management provides education to patients and families on preventing and controlling symptoms, information about understanding indications and implications of disease-specific strategies and recognition of the psychosocial needs of patients with chronic disease.

Examples of the types of patients we serve are highlighted in the stories below.

Bill

57 years old
Advanced Heart Disease

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Mary

58 years old
Advancing Oncology Patient

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Rebecca

80 years old
Advanced Alzheimer’s Patient

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Brenda

58 years old
Lupus, Rheumatoid Arthritis and Cognitive Decline

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Grace

89 years old
Advanced Cardiac Disease

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Harold

91 years old
Metastatic Prostate Cancer

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  • Bill

    Bill is a 67 year-old retired steel worker who has smoked for over 50 years. Although he developed heart disease that required by-pass surgery twice, he continued to smoke. Bill was hospitalized after he became severely short of breath and passed out, which frightened his wife, Helen. Bill was found to be in respiratory failure from COPD with bilateral pneumonia and heart failure. Upon discharge from the hospital, his hospitalist indicated that Bill would need further counseling and support to help understand the nature of his progressive disease and his continued resistance to treatment options including pulmonary rehab, home oxygen, smoking cessation and advanced care plan options. Bill’s wife was very anxious that he may collapse again at home. A Heartland Advanced Disease Management nurse practitioner was consulted. She began discussion regarding what Bill and Helen understood from the hospitalist regarding Bill’s condition. The NP addressed the nature of Bill’s disease, ways of coping and treatment options available. She also recommended an Alert Bracelet and First Responder Alarm and provided Helen with a referral to a support group. Bill agreed to the use of supplemental Oxygen therapy and is now on a combination bronchodilators and inhaled corticosteroids for symptom management of chronic, progressive dyspnea.

  • Mary

    Mary is a 58-year-old female who is married and has two children. She was diagnosed five months ago with advanced head and neck cancer. She has been receiving curative treatments including surgical resection, chemotherapy and radiation therapy. Last week her physician informed her that the cancer progressed to her lung. She is at home with her family and up until she was diagnosed, she was assisting with caring for her elderly father who still lives in his own home. In addition, her daughter is due to be married in one month. Over the last few weeks, Mary has experienced the feeling of suffocation which has increased her anxiety level. Her physician prescribed intermittent oral morphine to relieve her sensation of breathlessness, but Mary has been hesitant to use it as she heard it was “addicting.” At this point, Mary’s physician made a referral Heartland ADM requesting that the NP assist with education and support to Mary and her family regarding misconceptions associated with morphine use. Based upon the NP’s observations with Mary and her family, the plan of care was adjusted to increase psychosocial support to Mary. In addition, the NP prepared the patient and family on treatment strategies, drug choices and therapeutic ranges of doses specific to the needs of this type of cancer and its potential progression.

  • Rebecca

    Rebecca is 80 years-old and has had dementia for seven years. She is in the advanced stage of the disease and has been experiencing frequent silent aspiration with bilateral pneumonia for which she has been re-hospitalized three times in the last five months. She is currently in an assisted living facility that specializes in dementia care. Rebecca was evaluated by Speech Therapy four months ago at which time a feeding tube was recommended secondary to poor swallowing with risk of repeated aspiration. Her family refused the recommendation for feeding tube placement as well as a referral for hospice services. Heartland’s nurse practitioner was contacted for a consult. Heartland ADM is providing education to the family regarding the risks and/or benefits associated with feeding tubes and support with discussion regarding advanced care planning.

  • Brenda

    Brenda is a 58 year old female with a history of Lupus and rheumatoid arthritis. She was completely independent but began to experience a slow decline over the past four years. She progressed from mild memory loss to withdrawal, depression and weight loss. She began to miss work and experienced countless hospitalizations with no improvement. Brenda became so agitated with paranoid delusions and frightening hallucinations, that she would not allow anyone to provide care for her. She lost interest in her hobbies and her behavior caused her to lose her job and her home. Her sister, who is Brenda’s main support, became very distressed about Brenda and started experiencing her own health issues.

    An Advanced Disease Management nurse practitioner was consulted and realized that something was not normal with this patient’s decline and behavior. The nurse practitioner recommended multiple changes in medications to assure that the behaviors were not side effects of pharmacological interventions. The nurse practitioner then worked to get the patient in to see her rheumatologist and a neurologist. Brenda was evaluated and placed on medication that resulted in a complete change of symptoms. Brenda is back to enjoying her hobbies and time with her sister. She is gaining weight and regaining some of her strength through a therapy regime.

  • Grace

    Grace, an 89 year old female, was diagnosed with end-stage cardiac disease in a skilled nursing center. Her family was adamantly against calling in hospice so a nurse practitioner from Advanced Disease Management was consulted to review possible palliative services. The nurse practitioner ensured that the patient was comfortable and worked diligently with the family to prepare them for Grace’s death and managing grief that would follow. The family stated that the nurse practitioner “made a very difficult time easier.”

  • Harold

    Ninety-one year old Harold is battling with metastatic prostate cancer. He struggled to communicate about and deal with his disease and pain. While Harold was in the hospital, an Advanced Disease Management nurse practitioner was asked to consult. The nurse practitioner took the time to learn to communicate with Harold and answered all of his questions about his disease process and the pain. She reviewed pain control solutions with him and explained what to expect. He has rebounded and this has made a huge impact on him and his family’s well-being.

Get In Touch

Learn more about Advanced Disease Management by contacting us using the form below or at: 800-507-4329 or admin@NPcarepartners.com