For a patient who has been hospitalized or rehabilitating for many days or weeks, transitioning from a hospital or skilled nursing facility back home can be stressful and sometimes difficult. A transitional care home visit by a Nurse Practitioner can help smooth the way and keep patients on the track to getting better. This type of clinical home visit is made within two weeks of discharge.
Home visits by a Nurse Practitioner (NP) are important to your overall continuity of care and will enable your transition to a home setting go more smoothly. The NP will have direct access to medical records from the facility you recently discharged, enabling a more concise discussion about your current status and situation with the provider team to identify clinical concerns or changes in your condition that may have occurred since your return home. This continuity of care greatly enhances the safe transition back to your home.
The Nurse Practitioner performing your home visit is an experienced clinician. They can write prescriptions, refills, and/or lab orders as necessary, which is very different than what Home Health services can offer. Nurse Practitioners work alongside Home Health services to supplement care. Home Health is provided by a separate certified agency where nurses (RNs and LPNs), and sometimes therapists (PT, OT, ST) and social workers come to your home intermittently over a period of weeks to provide nursing therapy and educational instruction regarding your condition. Palliative Community Resource Nurse Practitioners are not affiliated with your home health services.
Like a physician or Nurse Practitioner office visit, you may be responsible for a copay of approximately $35, depending on your insurance.
Preventing Readmissions
The United States has a hospital re-admission problem. About 1 out of 5 patients admitted to hospitals in America are re-admitted within 30 days. Those re-admissions are expensive. The average cost of 1 hospitalization in the U.S. is $15,000 but the cost of hospitalization plus 1 re-admission is $33,000. In other words, re-admissions are more costly than the initial admission.
Medicare’s solution: fine hospitals with higher re-admission rates. In 2017, Medicare penalized 2,597 hospitals for readmissions over the national average. (Medicare.gov)
Patients adherence after discharge is a concern. With a transitional care visit by a Nurse Practitioner, an additional layer of assessment, support and instruction can be can help ensure patients have the help and encouragement they need following hospital and skilled nursing facility discharge.
The specialized oversight and care that Transitional Care Management offered by Nurse Practitioners helps patients with life limiting illnesses stay at home and out of the hospital.
Transitional Care Management Frequently Asked Questions
What is a Transitional Care Home Visit?
The transition from a hospital or Skilled Nursing Facility to your home can be stressful, tricky, and challenging. A transitional care home visit is a clinical visit conducted by a Physician or Nurse Practitioner on patients discharged directly to their home from a hospital or Skilled Nursing Facility.
Why do I need a Home Visit by a Nurse Practitioner?
A home visit by a Nurse Practitioner helps identify any clinical concerns after you have returned home and generally provides a smoother transition back to your home environment. If, for example, medication or lab orders need to be written or adjusted before you can get to your regular primary care physician's office, the Nurse Practitioner can take care of this.
What is the difference between Home Health and a home visit by a Physician or Nurse Practitioner
Home Health is an ongoing service provided by a specific home health agency in which Nurses and sometimes Therapists and Social Workers come to your home to provide you intermittent clinical and instructional care. The home visit performed by the Nurse Practitioner is conducted so patients also have a higher-level clinical assessment performed in their home in the first 7-14 days after being discharged from a hospital or Skilled Nursing Facility. The Nurse Practitioner performing this visit is experienced in adult and geriatric care and can provide you a prescription and/or lab orders if necessary. Moreover, in the case of a Nurse Practitioner, he/she is a colleague of the Nurse Practitioner who has taken care of you in the Skilled Nursing Facility and he/she works in collaboration with the very same physician(s) for your care.
How much will a transitional care home visit cost me?
You may be responsible for a copay of approximately $35 for this visit, depending upon your insurance.
Can I or should I still see my regular primary care physician?
Absolutely! You should see your primary care physician as soon as you can safely get out of your home to visit him/her in their clinic. Information from the transitional care home visit will be shared with your primary care provider directly, and the same information will be provided to you to discuss at your next appointment. This service in your home in no way replaces the current care you may already be receiving from a physician. It is intended to identify any changes in your condition or status that may occur in the first 30-day transition from hospital or skilled care to your home environment. Additionally, the Nurse Practitioner will provide education about your condition, and answer questions you may have about your care plan, progress, or goals.
What happens if I cannot get an appointment with my Primary Care Physician within a month and need to be seen
It is very important that you schedule an appointment with your Primary Care Physician and that you do your best to keep that appointment. Also, some health conditions place patients at higher risk, which may qualify them for a second home visit. If you cannot get out to see your Primary Care Physician or believe your symptoms or condition may be worsening, call your Nurse Practitioner within the 30-day period following your discharge and they will follow up with you.
What can I expect from the Nurse Practitioner during a Transitional Care Home Visit?
The goal of Nurse Practitioner home visits after a hospital or skilled nursing facility stay is to help patients bounce back to good health, not back to the hospital. Transitional Care Management can help you recover at home.
During a visit within 14 days after discharge, the Nurse Practitioner will provide the following:
- A brief health history
- A complete physical examination
- An Environmental Safety Assessment
- Education about new treatment and health conditions
- Goals of care review
- Medication Reconciliation and Medication or lab orders as necessary
- Coordination between your Providers at the Hospital or Skilled Facility and your Provider in the community
