Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.¹ Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.² Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.²

A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers.