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 it’s 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 a recent webinar on Home Visits: Assessing Complex Patients Post-Discharge to Reduce Readmissions.
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.
"About 20-25 percent of my time is spent on the pre-work and post-work around home visits, such as seeing the patient in the hospital, reviewing hospital notes and the discharge summary, coordinating with the PCP and care coordinator, and making follow-up phone calls."
Among the process and outcome measures Stanford uses to evaluate the effectiveness of the home visits, which are separate from traditional home care, is the Patient Activation Measure®, which identifies a patient's level of engagement in their own care.
Although program results are anecdotal at the one-year point, Stanford hopes the home visits will not only reduce rehospitalizations in the approximately 200 high-risk patients it serves, but also reduce lengths of stay, empower patients to partner in their care, improve patient satisfaction and bridge the hospitalist-primary care provider gap, Ms. Valcourt noted.
Ms. Valcourt provides more details on Stanford Coordinated Care's home visits program in this interview.