Congestive Heart Failure & Diabetes

Community Visiting Nurse Association (CVNA) announced in August, 2011, that it received a grant from the Robert Wood Johnson Foundation through its New Jersey Health Initiatives program to support the “CARE” program (A Collaborative Approach to Reach Patient Empowerment), designed to reduce the number of patients who return to the hospital as a result of difficulty managing chronic health conditions such as Congestive Heart Failure and Diabetes.   

CARE is a collaborative effort among eight Somerset County Providers seeking a joint approach to provide quality care, patient self management and empowerment to individuals with chronic diseases such as Congestive Heart Failure and Diabetes.  The program’s collaborating providers are Somerset Medical Center, Laurel Circle at Bridgewater, Bridgeway Care Center, Somerset Valley Rehabilitation & Nursing Center, Green Knoll Care and Rehabilitation Center, Greenbrook Manor Nursing and Rehabilitation Center, and Raritan Health and Extended Care. 

Services start with an assessment by the nurse case manager and include monthly visits to monitor the patient’s condition and progress.  Services include:      

  • Risk Profile
  • Physical Assessment
  • Glucose Monitoring
  • Oxygen Saturation Monitoring
  • Disease Management Education
  • Environmental/Safety Assessment
  • Pharmacist Medication Review
  • Nutritional Counseling
  • Social Work Evaluation
  • Physical Therapy Evaluation
  • Exercise Plan
  • Telemonitoring (if eligible)
  • Community Referrals (as needed)

The team works with the patient to develop a customized plan that offers the services that will be most beneficial.  Services are provided free of charge to eligible patients who live in Somerset County.

To check eligibility for this program or to receive additional information, call our Community Services Coordinator at 908-725-9355 ext. 2201, or contact us by e-mail.