Kate, I worked for an agency that did just this very thing with some diagnosis. CHF, CVA, Post Joints, COPD, and to some degree diabetes,(even wound care patients) but that's a tricky one. With managed care companies and less reimbursement, our agency wanted to limit visits and teach and make everything work. We would often keep them the whole cert period, front load visits and then fall into a skip pattern. Then on the "off weeks" there were disease management nurses in the office that made calls during those weeks with a check sheet of questions to ask the patient. It worked very well for most patients, problems arose with me when the patient didn't quite fit into the "box" and I would increase visits based on my assessment. I would then have to spend hours emailing the bean counters in the office trying to justify why this patient needs more visits.
The pathways had very specific things to teach at each visit, and what to assess from the past that kept the patients on track. They developed teaching books that were to be given to the patient. The books were written on a third grade level and they made them available in spanish.
Lots of education, mostly via phone conferencing and webinars went into education to the staff when a new program would roll out. You are not dreaming, it is possible. However, you must be willing to put a lot of work into it on the front end so that it can work.
By the way, I worked as a field nurse for 15 years. I just got a little burnt out with all the paperwork. Visit demands for full time staff seem much higher than what I read on this site. I case managed 25-50 patients at all times. I drove 700 miles a week. My friends called me the "road warrior". But I sadly hung up that hat 3 months ago. I miss it some, but the change has been great, I feel my life is so much more relaxed and I'm enjoying the break. I took a new job. I'm thinking of maybe going back and doing some PRN visits with them, just to keep my hands and brain in the game of home health!