This foundational course addresses the three parts of the patient home visit and information and processes that surround and support effective and holistic home visits. This includes a practical and holistic definition of a home visit, the use of the care planning process through the visit, the patient-related and other activities that occur during a skilled visit, and strategies to document care that was provided during the visit. This course will also explain why having exemplary organizational, clinical, and interpersonal skills is key to making value-based home visits. This is because numerous and complex facets of care, including the patient's goals, the plan of care, physician orders, care team members, the patient's environment, care coordination, and communication, all come together in this structured, person-centered encounter.
Kim Corral, RN, BSN, MA Ed, COS-C
Kim is a registered nurse with a master's degree in education and more than 30 years of home health experience. She is an experienced leader in home health care, having held both clinical and operational positions at regional and national levels for large corporate home health organizations. She brings a passion for providing the clinical…Read full bio
Tina Marrelli, MSN, MA, RN, FAAN
Tina Marrelli is the president of Marrelli and Associates, Inc., a publishing and consulting firm working in home care for more than 30 years. Tina is the author of 13 books, including the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (6th edition, 2018). Other books include A Guide for Caregiving: What's Next? Planning…Read full bio
1. The Home Visit: The Foundational Unit of Care
This chapter sets the stage for the most common care delivery mechanism in home care: the home visit. A holistic definition of an effective home visit will be offered as well as practical application, where the patients are "out there" and the environment of care may be as varied as the patients served and homes visited.
2. Pre-Visit Activities: Setting the Stage for Success
In this chapter, pre-visit activities will be featured. With this topic come the detailed organizational and other activities that must be addressed to have a successful planned patient home visit. This information applies to many kinds of home visits, including skilled Medicare visits, well-baby visits, infusion care, hospice home visits, and other kinds of home visitation programs and models. Pre-visit activities will include obtaining physician orders and other demographic and referral information, identifying needed paperwork, completing any pre-admission work on your tablet or device, and more. A patient example begins here and follows through the home visit and post-visit activities. It is important to note that physician orders and coordination and communication activities are a key part of all of the visit's components.
3. A Knowledge of Your Community Served: The Environment of Care
Home care and home care visiting occurs in the context of local communities. Familiarity with your community and its strengths, areas for improvement, and resources can help make home visits more successful and safe. A brief desciption of a "windshield assessment" will be given as well as a brief overview of safety when out in the community and in homes. There are safety implications for both the patient and the home care team in the home and community. Some of these risks and factors will be addressed.
4. The Patient's Unique Environment of Care: The Home
This chapter addresses the home visit and activities that occur once the team member arrives at the patient's home. Of course, there must be physician orders to see/assess/evaluate this patient. The initial visit may be the most important visit for a number of reasons. The visiting team member, such as a nurse or a therapist, has "new eyes" and can use this objective presence (only once!) to observe and use all senses to value incoming input and data. This is also the first time we meet our patient and is the initial assessment visit from which we start to create the actionable plan of care. During this visit, we clarify expectations and schedules and explain home care and home care services. We also begin the interactions that form the basis for the patient experience. This chapter addresses the processes to create a workable plan of care. This includes reviewing all the noted data from all sources, such as interviewing, observing, and the use of all of our senses for more data collection. We obtain/explain/complete the initial paperwork, including consent, and the mutually agreed-upon goals are developed with the patient and family/caregivers.
5. Post-Visit Activities: Pulling It All Together
This chapter addressed the activities that take place after the visit has concluded. Sometimes we contact other team members, such as the physician (to collaborate/confirm the plan of care or to clarify any orders) or an aide supervisor or therapist, all to coordinate care and communicate information while at the patient's home. At this stage, it is important to clearly identify the patient's skilled care needs and validate that this patient and their care needs meet your organization's admission criteria.
6. Visit Evaluation: Reviewing Care and Documentation
This chapter provides a review of some of the most important parts of home care documentation after a patient visit: the comprehensive assessment, the plan of care, and the documentation of the care and services provided at this visit.
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