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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

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

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.