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VNSNY Chronic Care Expertise

Complex Illness Management

Patients with complex illness have multiple chronic
conditions and are the greatest challenge faced by the
American healthcare system. The average VNSNY patient
has four chronic conditions and requires coordinated
care from multiple providers to be maintained safely in
the community. Common complex illness combinations
include heart failure, COPD, asthma, wounds, depression
or anxiety, and social issues.
Our masters-prepared, nationally certified professionals
collaborate with other disciplines, draw on each other’s
knowledge and expertise to provide evidence-based,
clinical guidelines to assist clinical staff and improve
patient care, including:
• Advanced heart failure and end-stage diabetes and
the impact on functional status
• Advanced illness and how to start an end-of-life
conversation
• Geriatric syndromes, functional decline and the impact
of rehabilitation on quality of life
• Evidence-based pharmacological and best practice
non pharmacological management
• How to use SBAR to discuss clinical concerns with

primary and specialty physicians

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