As a Triple Aim clinic, the charter of Stanford Coordinated Care (SCC) is to manage the care of those 10 to 20 percent of Stanford University and Stanford Hospital employees deemed high utilizers.
To keep these high-risk patients out of the hospital and emergency rooms, SCC launched a care transitions initiative crafted around home visits.
In Home Visits for High-Risk Patients: Tools, Timing and Outcomes, SCC's clinical nurse specialist, Samantha Valcourt, MS, RN, CNS, describes the home visits program she developed and implemented for SCC as part of its care transitions initiative for high-risk patients.
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This 25-page special report provides the following details:
- The timing and process that Stanford Coordinated Care follows for setting and conducting the home visit;
- Tools for stratifying patients in need of home visits;
- Key steps in evaluating risk factors in the homes of high-risk patients;
- Reliance on a personal health record (PHR) that travels with the patient during various care transitions;
- Strategies for determining patient's level of activation;
- The number one issue uncovered during home visits that may lead to readmissions;
- Fielding an interdisciplinary team, including a highly functioning medical assistant, embedded within the clinic to support the home visit function and improve care transitions;
- and much more.
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P.S. -- You may also be interested in these home visit resources: