Patients with symptoms indicating impending disjunction, such as new or exacerbated:

• Tenderness or pain in joints
• History of joint swelling
• Subcutaneous nodules
• Fever
• Malaise, discomfort

Patients who:

• Are experiencing increasing arthritic pain
• Are Initiating a new medication regimen
• Are at high risk of falling
• Need strengthening, gait training or mobility aids
• Need assistance during post-surgical recovery
• Would benefit from a maintenance exercise program to reduce risk of deformities
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from skilled therapy for strengthening or to avoid contractures
• Would benefit from teaching on pain management techniques
• Would benefit from joint protection education or teaching on the use of assistive devices.

Patients with new or exacerbated:

• Tendency to hemorrhage
• Sepsis
• Skin itchiness, eruptions and hemorrhages
• Other comorbidities, including cardiac conditions
• Pernicious anemia, impaired iron absorption
• Weakness and severe weight loss
• Diagnosed malignant lymphoma

Patients who:

• Have abnormal lab values
• Are post-op splenectomy
• Are Initiating a new medication regimen
• Are at high risk of falling
• Are at increased risk of in infection or impaired tissue integrity
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from education on blood disorders
• Would benefit from teaching on avoiding recurring infection

Patients with new or exacerbated:

• Pain
• Weight loss
• Loss of function
• Weakness or malaise
• Dietary intolerance
• Deterioration of patient’s condition

Patients who:

• Need post-operative care following mastectomy, laryngectomy, ostomy, etc.
• Are receiving chemotherapy, radiation or proton therapy
• Are Initiating a new medication regimen
• Are at high risk of falling
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from therapy to maintain strength and function for continued medical intervention
• Would benefit from teaching on new diagnosis, treatments or medication regimen
• Have a diagnosis with limited prognosis and may ultimately transition to hospice

Patients with new or exacerbated:

• Anorexia, nausea or vomiting
• Peptic ulcer
• Diverticular disease
• Abrupt weight loss
• Suspicion of hematemesis, melena or hematochezia, blood in vomit or stools
• Cirrhosis of the liver with weakness, fatigue, jaundice or fever Malnutrition

Patients who:

• Have recurrent fecal impactions
• Are receiving hyperalimentation feedings
• Had recent gastric surgery or gastrostomy
• Are receiving nasogastric feedings
• Are post-op ostomy or ostomy with complications
• Are Initiating a new or changed medication regimen
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from teaching on specified dietary modifications
• Would benefit from speech therapy for dentition and swallowing

Patients with new or exacerbated:

• Chronic Obstructive Pulmonary Disease (COPD)
• Lung cancer
• Pneumonia, viral or bacterial infection
• Pulmonary embolism
• Other respiratory disorders

Patients who:

• Are post-op thoracic surgery
• Have unstable or fluctuating vital signs
• Are initiating the use of nebulizers or inhalers
• Have upper respiratory infection combined with other medical conditions, such as heart failure / abnormal enlargement
• Are initiating percussion or postural drainage techniques
• Are taking antimicrobial medications
• Have Activities of Daily Living challenges related to respiratory disorder
• Would benefit from teaching pulmonary hygiene, clearing mucus and secretions from the airways.
• Would benefit from therapy to teach energy conservation.
• Would benefit from daily remote telehealth monitoring of vital signs to identify trends and potential exacerbations
• Have a diagnosis with limited prognosis and may ultimately transition to hospice.

Patients with new or exacerbated:

• Joint Replacement
• Fractures of the hip, lower leg, ankle, pelvis
• Compression fracture of vertebrae
• Amputation of lower or upper extremity
• Paget’s disease of the bone
• Degenerative joint diseases

Patients who:

• Are post-op joint replacement (hip, knee, shoulder)
• Are at high risk for falls or post-operative complications
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from pain management medication review, checking all medications, nutritional supplements and vitamins in the home
• Would benefit from observation, evaluation and restorative nursing
• Would benefit from physical therapy intervention for severe bone pain or bone deformities

Patients with new or exacerbated:

• Indwelling catheters
• Urinary tract infections
• Vesicourethral suspension, bladder / urethra
• Hematuria, blood in the urine
• Renal failure, accompanying hypertension
• Cancer of the bladder or prostate
• Altered fluid or electrolyte balance

Patients who:

• Have abnormal lab values
• Are post-op renal or urological surgery
• Had a sudden weight gain
• Have elevated or unstable vital signs
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from bladder training for incontinence
• Would benefit from specific dietary modification and teaching
• Would benefit from therapy to maintain strength and ADL function
• Have a diagnosis with limited prognosis and may ultimately transition to hospice

Patients with new or exacerbated:

• Fluctuation or instability in vital signs
• Orthopnea, dyspnea, shortness of breath
• Chest pain or changes in pain patterns
• Peripheral edema, swelling
• Syncope and fainting
• Hemoptysis, coughing up blood
• Loss of function or control
• Transient ischemic attacks
• Aphasia, dysarthria, swallowing or cognitive disorders

Patients who:

• Had recent myocardial infarction, heart surgery or pacemaker insertion
• Are initiating a new or changed medication regimen
• Have had recent or frequent hospitalizations
• Have had frequent or recent emergency visits
• Would benefit from teaching on energy conservation
• Would benefit from strengthening to improve Activities of Daily Living
• Need extensive dietary modification and teaching
• Would benefit from daily remote telehealth monitoring of vital signs to identify trends and potential exacerbations
• Have a diagnosis with limited prognosis and may ultimately transition to hospice

Patients with new or exacerbated:

• Age-related macular degeneration
• Cataract
• Diabetic retinopathy
• Glaucoma
• Incidence of falls

Patients who:

• Home safety assessment, including risk factors, self-care ability, meal preparation, medication use and other ADLs
• Teaching on compensation techniques using contrast, color, lighting, tactile orientation and optical aids
• Teaching on ADLs, including meal preparation, mobility, hygiene, household maintenance and safety
• Medication review, checking all medications, nutritional supplements and vitamins in the home, along with their potential impact on visual function
• Daily telehealth monitoring of vital signs to identify trends and potential exacerbations