Miller is part of a research team studying whether patient-centered post-discharge care, including a home visit soon after discharge, can reduce ED revisits and admissions among patients with acute heart failure. A two-person team conducts a home visit and assesses the patient’s status, level of knowledge, and capability to manage their disease. According to Alan Storrow, Associate Professor of Emergency Medicine and study co-investigator, the study team has learned that visiting patients in their home allows providers to “meet patients where they are” along the healthcare continuum and to tailor the patient’s care plan according to their individual needs, goals, and priorities.
In the home setting, patients are more likely to feel relaxed, comfortable, and have a sense of control, in contrast to ED and hospital environments, which can be intimidating. Miller notes that this sense of control translates to a greater sense of self-efficacy and engagement in their own care, an openness and receptivity to education about how to manage their disease, and a sense of true partnership with the provider. Home visits can also provide valuable support and education to family members and caregivers.
Miller says that delivering care in the home has changed her entire perspective on patient care. She also notes that feedback from patients has been extremely positive, with many patients commenting that participating in the program is “the most powerful experience they have had in health care."
- Relationship building between patients and staff is key to the success of home visit interventions; begin forming a relationship before going to the patient’s home.
- Home visit interventions and care planning require clinical oversight; however, staff conducting home visits do not need to be clinicians.
- Emphasize a patient-centered approach and tailor the patient’s care plan based on their individual capabilities and goals; be flexible to each patient’s needs and priorities.
- Communicate with the patient’s primary care physician and other clinicians (e.g., cardiologist) at the outset and inform them about the patient’s involvement in the program. Emphasize that the visiting provider is a partner in the patient’s care and that the intervention complements and supports the patient’s primary care.
- Realize that interventions require concentrated support at the start of the education process, which can be reduced over time as patients learn to care for themselves.