Schedule more visits at start of care

See better outcomes, fewer hospitalizations

A hospitalization rate of 17% can be attributed to many factors, but the staff at Washoe Home Care in Reno, NV, are convinced that front loading the visit schedule is the key to a rate that is 11% below the national average.

"We start working with the patient before they are discharged from the hospital," explains Martina Petersen, RN, interim director of professional services for the agency. "We meet with the patient and the family caregiver to discuss what services home health will be able to provide and how often we will be coming to the home," she says. The key is to make sure expectations of the patient and the caregiver are realistic, she explains.

"If the patient lives alone or the family caregiver is not at home during the day, we evaluate the services that will be needed and we evaluate the patient's ability to care for himself or herself," Petersen says. If the home health nurse believes that the patient and the caregiver will be able to handle care at home but may be at risk for rehospitalization, the care plan will identify the patient as high risk and more visits will be scheduled for the first few weeks, she says.

Congestive heart failure (CHF) and chronic obstructive pulmonary disease patients, as well as elderly patients with elderly caregivers, are most often the patients who are seen more frequently at the start of care, says Petersen. "The extra nursing visits give agency staff members a chance to reinforce education and observe the caregiver or patient more closely as they change dressings or perform other activities," she says. The nurse can make sure medication is being taken as directed and that weight gain, oxygen levels or other vital signs are regularly recorded.

"If a holiday is approaching, we may also schedule an extra visit or time our visit so that we can meet with the patient and family to discuss extra precautions related to the holidays," says Petersen. "For example, ham is a traditional Easter meal, so we tell our CHF patients that we know they will eat the ham, but they need to eat in moderation and not add salt to anything," she says. "We want family members present so that when the patient refuses a second helping, they will understand the reason."

Even when patients are discharged from home care, the Medicare Health Maintenance Organization for their area has a program to continue management and evaluation of patients who are at risk for hospitalization, says Petersen. "We can stay in touch by telephone and even schedule visits to monitor the patient to prevent hospitalization," she says.

While nurses can evaluate edema, weight gain, medication use, and the patient's ability to take appropriate steps to control symptoms and avoid a crisis, there may also be psychological benefits to the additional visits, says Petersen.

"A few years ago, we had a patient who would have panic attacks on Fridays and would go to the emergency room and sometimes end up in the hospital," she says. "We started scheduling a visit with her mid-afternoon every Friday," she explains. The nurse would take her vital signs, ask how she was feeling, and talk to her. "We were able to stop her visits to the emergency room and keep her out of the hospital," she adds.

"Every now and then the front loading does strain staffing," admits Petersen. But the strain is short-lived as patients are discharged and other new admissions don't require extra visits, she says. "The benefits of front loading outweigh any extra effort on our part because the patient's outcome is better and the patient doesn't go back in to the hospital."