5 Pillars of Stanford Coordinated Care Home Visits

Connecting its high-risk patients to essential community resources is the fifth pillar of Stanford Coordinated Care's post-discharge home visits program.

This community connection for complex patients rounds out the four elements of the CTI that take place during each home visit: medication reconciliation, red flag education, follow-up physician visits, and a personal health record (PHR).

"We think itís important to get the patient hooked into whatever resources in the community can also help them to have good outcomes and not have to go back into the hospital," explained Samantha Valcourt, clinical nurse specialist with Stanford Coordinated Care, during last month's webinar Home Visits: Assessing Complex Patients Post-Discharge to Reduce Readmissions.

Samantha Valcourt

These local resources might include recruiting the patient's church group to visit or assist with meals preparation, she said.

Stanford visits their just-discharged complex patients in the home environment because it offers a close look at the individual's mobility, safety, nutrition status and support system. Of the five-point program, medication reconciliation is the most important task performed during the home visit, Ms. Valcourt noted.

Medication management problems immediately following the hospital discharge are a key factor driving hospital readmissions among high-risk Medicare beneficiaries, she said.

Just as it modified the CTI to suit its population, Stanford has added three questions to the HARMS-8 readmissions risk assessment tool developed by Care Oregon to identify patients who would benefit from a home visit. The post-discharge visits, which last about an hour on average, are conducted by Ms. Valcourt, an advanced practice nurse. Her preparation for the home visit begins when the patient is still in the hospital, she explains.

In case you missed this webinar, you still have a chance to watch this highly-rated program and learn the key features of Stanfordís Coordinated Care's home visit program.

Register to view the conference today or order your training DVD or CD:

You can "attend" this program right in your office and learn Stanford's four elements of care transitions; the role of home visits in its care transitions intervention; the timing and process for conducting home visits for high-risk patients; the key steps in evaluating risk factors in the home for high-risk patients; and how an interdisciplinary team is essential to support home visits and successful care transitions.

Itís so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer ó any time of the day or night, whenever convenient for you and your colleagues ó and benefit from the archived recording of the conference, including the Q&A period.

You'll get to listen to the question and answer session to hear the role of the pharmacist on the primary care team and during home visits; community resources and care transitions; engaging less activated patients; how to improve medication adherence; the interaction between home health and home visits aimed at coordinating care; the time length of the typical home visit; and how palliative care is addressed during home visits.

To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Home Visits: Assessing Complex Patients Post-Discharge to Reduce Readmissions, please visit:

I hope you find it useful.


Melanie Matthews
Executive Vice President
The Healthcare Intelligence Network

P.S. -- You may also be interested in these home visit resources: