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, Arbor Glen 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. 

In addition, Community Home Care, working with a grant from the Somerset County Office On Aging, provides care to residents of Somerset County age 60 and over who have been diagnosed with congestive heart disease, chronic obstructive pulmonary disease (COPD) and/or diabetes or who have been classified as “at risk” for these diseases.  This Chronic Care Program delivers education and support to empower older adults to gain control of their lives through disease management, medication compliance, appropriate diet and nutrition and lifestyle changes.

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.