Disease Management

Continuum staff uses documented "best practice" interventions and national therapy standards when managing specific disease processes. Our programs are designed to teach patients and caregivers how to self manage their disease process. Our focus of care is to prevent avoidable rehospitalizations. Specialized clinical pathways are used for Heart Failure, COPD, Incontinence, Wound Healing, Ostomy Care, Diabetes, Surgical Aftercare, Rehabilitation, and Psychiatric Nursing.


Continuum's cardiac disease management program has been proven to reduce the patients need for emergency care and rehospitalizations for their cardiac diagnosis through the use of clinical best practices that emphasis patient self management of medication management, weight control, diet and exercise and recognition of early cardiac warning signs.

Appropriate referrals include patient's with diagnosis of congestive heart failure, heart transplant, CABG, coronary artery disease, hypertension and cerebrovascular accident.

COPD  Program

Continuum's COPD management program has proven to reduce the patients need for emergent care and rehospitalizations for our patient's with COPD. The program utilizes clinical best practices with a focus on patient self management through:  teaching self-management, early intervention recognition, medication management, prevention of exacerbation, and exercise.  

Rehabilitation Services

The Continuum therapy program ranks higher than National , State and regional outcomes for improving ambulation, transfers and self-care. Rehabilitation therapy services include physical therapy, occupational therapy and speech therapy.  Services are provided to improve problems with mobility, self-care, communication, pain, open wounds, incontinence and cognition.  Our therapy staff have advanced training and clinical specialist certification in the areas of geriatrics, neurology, cardiopulmonary, wound care and dysphagia (swallowing) management.

Wound/ Ostomy Specialty

Continuum utilizes a multidisciplinary team setting in the treatment of medical/surgical. We are have Registered Nurses and Physical Therapist that are certified in the clinical management of wounds. 

Continuum provides specialized consultation for wound/ostomy assessment and treatment recommendation from a certified WOC Field Nurse (Wound, Ostomy and Continence).   


The Continuum diabetes disease management program was developed based on the national standards set by the American Diabetes Association (ADA). Patients and caregivers are taught self-management to control diabetes and the complications. The program utilizes clinical best practices with a focus on patient self management through medication management, weight control, diet and exercise, recognition of early warning signs, and prevention.

Surgical Aftercare

Continuum provides Surgical Recovery. Research has proven that patient's heal and recover better at home.  Our program improve surgical aftercare outcomes through improve ambulation and transfers through strengthening, balance, wound care and safety training.

Behavioral Health - Continuum's Psychiatric Nursing Program

Continuum's Behavioral health program is staffed with experienced Psychiatric Nurses. These nurses coordinate care and services with psychiatrists and or primary care physicians. Our programs goal is to help patients remain at home, and avoid hospitalizations.

Pediatric Nursing Services

Continuum provides pediatric services to those children who need home health care on an intermittent basis.  Our pediatric nurses are trained in pediatrics.  We provide infusion and enteral therapy services, wound care, medication education.

Infusion Services

UVA's Continuum home infusion service consists of a specialized team of pharmacists and registered nurses.  Nurses provide patients with teaching and support that is needed to make sure patients feel at ease with their IV therapy at home. 

From our on-site pharmacy, we provide numerous IV therapies such as antibiotics and chemotherapy, for home use, with easy use infusion pumps and supplies. Which we deliver right to our patient's homes. 

The Infusion Pharmacists work closely with the home care nurses and physicians to ensure that treatment goals are being met and care is coordinated. The Continuum Infusion Therapy Services also includes a nutritional support team that closely monitors nutritional needs.