This VNAA Best Practice includes the following critical interventions and actions:

• Utilize the Institute for Healthcare Improvement (IHI) hospitalization risk assessment tool as part of the initial admission evaluation to determine risk of hospitalization.
  
• Evaluate if the patient needs a second visit based on their score on the IHI tool (at moderate to high risk of hospitalization). Patients identified as high risk should also receive a second visit within 48 hours of discharge from the hospital.
• On the first or second visit determine if the patient needs frontloading of nursing visits in the first two to three weeks, based on a diagnosis of heart failure or chronic obstructive pulmonary disease or if the patient is on high risk medications.
• Document visit frequency on the patient plan of care (Form 485) for 60 percent of nursing visits in the first two weeks of service for high-risk patients.
• Determine if the patient would benefit from telemonitoring (if available) based on diagnosis and incorporate into plan of care.
• Determine organizational barriers to frontloading during the first two visits and for the first two to three weeks for identified patients. Include staffing needs in this determination.
• Educate all staff on use of the IHI tool, confidence ruler, zone tools (linked below) and high risk medications.
• Educate all staff about the importance of this practice to get staff buy-in for the practice to be implemented successfully.
• Monitor plans of care to ensure that the strategy is being implemented.
• Track results (readmission rates) and communicate outcomes to all staff.
• Measure productivity in such a way as to allow the same clinical team to see patient over the first two weeks.
• Implement telemonitoring or telephonic protocol support to supplement visits for first 30 days.

The tools linked below were evaluated by the VNAA Best Practices Work Group and are offered for duplication and use. All are used with permission from the authors and/or organizations that originated the material. Please retain all logos and citations where authors/originators are listed on these resources.