Assessing Readmission Risk to Prioritize Home Visits for Complex Patients

Modifying a popular hospital admissions risk assessment tool for its own use helps Stanford Coordinated Care to prioritize home visits for its roster of high-risk patients, all of whom have complex chronic conditions, explains Samantha Valcourt, MS, RN, CNS, Stanford’s clinical nurse specialist. Stanford’s HARMS-11, based on Iowa Healthcare Collaborative’s HARMS-8 hospital risk screening tool, looks at individuals’ utilization, social support and medication issues, among other factors, to measure a patient’s risk of readmission.

The resulting home visits, a critical component of Stanford’s care transitions management program, help to uncover health challenges the complex chronic patient may still face, including four common medication adherence barriers Ms. Valcourt describes in this interview.

Samantha Valcourt shared how Stanford’s Coordinated Care uses a home visit assessment to improve care transitions post-discharge during a December 19, 2013 webinar, Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions.


Length: 6:28 minutes

Health Coaching’s Value in Accountable Care and Medical Homes

Primary care and the patient-centered medical home offer a great opportunity for health coaches to become allies with patients in improvement of their health, notes William Appelgate, executive director of the Iowa Chronic Care Consortium. Individuals with the highest health risks should be given priority, but those on the cusp of a serious health event also merit coaching assistance, he says. For providers new to the coaching conversation, Appelgate shares three benefits of incorporating health coaches in the care process — including the upping of their ‘outcomes game.’

Bill Appelgate and Alicia Vail, RN health coach for Ochsner Health System, shared how an evidence-based health coaching focus drives returns in a value-based payment delivery system during a June 19, 2013 webinar, Health Coaching’s Value in Accountable Care and Medical Homes.


Length: 8:35 minutes

Identifying Functional Decline in Chronic Care Patients To Reduce Preventable Healthcare Utilization

Functional decline in an elderly person can be the first indicator of a chronic condition ready to snowball out of control. Patricia Zinkus, director of case management at Fallon Community Health Plan, and Susan Legacy, FCHP’s senior manager of case management, describe how their collaborative multidisciplinary intervention monitors for these changes, and why the program’s social component is just as critical as home visits and case management outreach.

Ms. Zinkus and Ms. Legacy shared details from FCHP’s risk-sharing model during Identifying Functional Decline in Chronic Care Patients To Reduce Preventable Healthcare Utilization, 45-minute webinar on April 27, 2011.




Length: 3:26 minutes