Karen Miller, RN, is a care transition research nurse who coordinates operations for a PCORI-funded multi-site study, which examines whether patients with acute heart failure who receive patient-centered post-discharge care, including a home visit soon after ED discharge, close outpatient follow-up, and subsequent coaching calls, will avoid subsequent ED revisits and inpatient admissions.

Conducting home visits with patients recently discharged from the hospital or emergency department can be a valuable strategy to improve care transitions for patients. According to Karen Miller, RN, a research nurse who specializes in care transitions, home visits enable providers to get a better understanding of the patient within the broader context of their life, and help foster “an intimacy that you cannot achieve in the hospital—patients often share information during home visits that is not typically shared in the hospital setting.”

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."

Advice for Others

  • 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.

What's Happening at PCORI?

The Patient-Centered Outcomes Research Institute sends weekly emails about opportunities to apply for funding, newly funded research studies and engagement projects, results of our funded research, webinars, and other new information posted on our site.

Subscribe to PCORI Emails


Hand pointing to email icon