Home Visits Help Reduce Readmissions for At-Risk Medicare Patients.

Abstract

Hallmark Healthcare’s Community-based Care Transitions project created the position for transition facilitators who visit at-risk patients in their homes and achieved significant decreases in readmissions. Transition facilitators work as a team with inpatient case managers, a nurse practitioner, and a pharmacist. They see at-risk patients in the hospital, visit them in their homes within three days of discharge, set up any community services needed, and follow them by telephone for 30 days. The nurse practitioner and pharmacist make home visits to patients who need extra assistance in following their treatment plan or medication regimen.