Many patient-centered medical home (PCMH) initiatives have added home visits to care transition management to reduce avoidable hospital readmissions and ER utilization. Jessica Simo, program manager with Durham Community Health Network for the Duke Division of Community Health, describes likely candidates for home visits, the structure of a typical home visit and recommended staff training.
HIN: Which diagnosis or patient profile benefits most from a home visit?
(Jessica Simo) As a general rule for the patient population we serve, the people who get the most home visits are middle-aged individuals with at least two chronic health conditions. These are not generally healthy individuals who had one adverse event that brought them to our attention. These are people living day in and day out with chronic health problems they struggle with managing. Those people benefit the most from the amount of time it takes to do a home visit.
(Jessica Simo) The average home visit lasts 45-60 minutes. It would be longer for the initial home visit when an assessment is being done—where the Care Partner (a partnering stakeholder from across the Duke University health system and the Durham community) collects information for the first time about medications the patient takes, their sources of support, ADL deficits, etc. Those visits tend to be a bit longer, certainly an hour at a minimum, but once that rapport has been established, the weekly visits are often less than an hour. They become briefer as a patient transitions from phase one to phase two of the Care Partners Pathway because there is less to talk about at that point. This is a good thing; it means they are improving.
The home visits are structured around assessments and protocols, but as the home visits progress and the care partner becomes more familiar with the patient, there is less reliance on assessments and more on follow-up from the previous week.
HIN: How do you prepare and train staff to conduct home visits?
(Jessica Simo) The best way to prepare somebody to do home visits is to have them shadow a more experienced staff person. There are too many independent variables at play when you go into somebody’s home and you just don’t have control over that environment. Nor should you. It’s impossible to anticipate every possible scenario. Therefore, we do a lot of shadowing for at least a month before someone does a home visit on their own.