What happens during the first few days a patient is admitted to home health care can have a tremendous impact on the patient’s outcome. Patients should be evaluated soon after admission to home health to ensure safe, timely, efficient, effective care and to prevent hospitalization or re-hospitalization. During this time, the home health professional should address the need to make a follow-up appointment with the attending physician.But these early visits involve more than assessment and scheduling. This can be an especially vulnerable time--emotionally and physically--for patients, and they often feel overwhelmed and anxious.

Why perform an initiation visit in the first 24 and follow-up in 48 hours of hospital discharge or referral to home care? Evidence demonstrates that patients need to be evaluated early in home care through effective transition care programs to prevent hospitalizations. Some components of this transition program are medication reconciliation, identifying high risk patients and working with patients/caregivers to identify a change in their condition as these are all factors in hospitalization. Evidence suggests that certain diagnoses and clinical factors predict hospitalization (Rosati & Huang, 2007). Research demonstrates that 33 to 66 percent of medication-related hospitalizations are the result of poor adherence (2011). Coleman et.al. (2006) found that patients who received care using his Four Pillars methodology (which include exacerbation of condition) had significantly lower readmission rates than the control group at 30 and 90 days respectively. For more strategies to reduce readmissions from home health, visit the VNAA Preventing Readmissions From Home Health Module

How to use the VNAA Blueprint

The VNAA Blueprint can help your organization evaluate processes and adopt best practices for providing optimal care. Start with the training program, Implementation Guide: Critical Interventions in the First/Second Visits, which offers an overview of resources available through the Critical Interventions in the First & Second Visits best practice topic area.

The training program learning objectives are as follows:

• Identify three interventions that should take place in the first 24 hours of discharge from the hospital or referral to home care.
• Discuss the importance of the Confidence Ruler in assessing the patient’s risk for hospitalization.
• Discuss three processes that are important in medication reconciliation.

Then explore the resources, critical interventions and measurement and evaluation tools by clicking on the boxes above.