4 Pillars of a Home Visit
Healthcare Performance Benchmarks
January 8, 2014Vol. IV Issue 1

4 Pillars of a Home Visit

4 Pillars of a Home Visit This Week's Challenge: To help manage care transitions for its complex patients, Stanford Coordinated Care, part of Stanford Hospital and Clinics, conducts home visits among its high-risk patients. According to Stanford Coordinated Care's clinical nurse specialist, Samantha Valcourt, after introducing the purpose of the home visit to the patient, there are four pillars to meet during the home visit: medication reconciliation, red flags, follow-up visit and personal health record (PHR). We wanted to learn more about these pillars.

Click here to view a printable version of the table.

What We Learned: "Medication reconciliation is where I focus a lot of my time and energy. I ask the patients to bring out all of their medication and to tell me exactly what they're taking and show me or tell me how they take it. [...] This is a good time to find out if there are financial restrictions; maybe they are waiting for authorization for a medication and it won't be ready for a week. In addressing the red flags or disease management pillar, I try to see if the patient understands why they were in the hospital. They can say, 'I wasn't feeling good,' but they don't necessarily know that when they were discharged it was a heart failure diagnosis, for instance. I like to go over what they need to be on the lookout for when they're at home. And then if it happens, what do they do? Is it something they can take care of at home or do they need to call one of their physicians? This is where teach-back is important."

— Samantha Valcourt, MS, RN, CNS, clinical nurse specialist with Stanford Coordinated Care.

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HINfographic: The 4 Ws of Home Visits.

Read related blog post: Home Visits Offer 'Eyes on the Ground' for High-Risk Populations.

Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions

Excerpted from Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions, a 45-minute webinar, during which Samantha Valcourt shared the key features of Stanford's Coordinated Care's care transitions program with a special focus on how they use a home visit assessment to improve care transitions post-discharge.

© 2014 Healthcare Performance Benchmarks by Healthcare Intelligence Network.
Editor: Jessica Fornarotto, jfornarotto@hin.com;
Publisher: Melanie Matthews, mmatthews@hin.com

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