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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.

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;

Table of Contents

• Home Visits: Assessing Complex Patients Post-Discharge to Reduce Readmissions
  • Background on Stanford Coordinated Care
  • Goals for Stanford Coordinated Care Transitions
  • Pillars of Stanford Home Visit Program
  • Stratifying Patients for Home Visits
  • Determining Patient Engagement Level
  • 5 Elements of the Home Visit
  • Revelations from Home Visits
  • Post-Visit Follow-Up
  • Challenges and Lessons Learned from Home Visits
• Q&A: Ask the Experts
  • Pharmacist’s Role on the Primary Care Team
  • Examples of ‘Fifth Pillar’ Community Resources
  • Factors Driving Home Visits
  • Working with Non-Clinic Doctors
  • Program Readmit Rates
  • Engaging Less Activated Patients
  • Reacting to Medication Reconciliation Problems
  • Home Visits for Patients with Home Health Services
  • Duration of Typical Home Visit
  • Telehealth and Remote Monitoring for Home Visit Population
  • Documenting Nursing Student Practices
  • Policy on Repeat Home Visits
  • Collaborating with Hospitalists on Care Coordination
  • Qualifications for Health Coaches on Chronic Care Team
  • Discussing Palliative Care Needs
  • Repeating Home Visits for Hospital Readmits
  • Populations Receiving Home Visits
  • Arranging Home Visits with Caregivers
  • PHR-EMR Interface
  • Percentage of Schedule Devoted to Home Visits
  • Origin of Home Visit Project
  • Qualifying for Home Visits
  • Medication Reconciliation During Home Visits
  • Who’s Conducting Home Visits
• Glossary
• For More Information
• About the Presenter