According to a study by Avalere Health and the Alliance for Home Health Quality and Innovation, the use of home healthcare results in fewer hospital admissions.  Community VNA’s home health care team offers these essential services to patients in their home improving their health or speeding their recovery as well as reducing hospital readmissions.

Case Management: Community VNA’s clinical staffs assess the patient, their environment and elements that impact their ability to recover.  They work in collaboration with discharge teams from hospitals and rehab facilities and directly with physician offices to deliver seamless care and ensure patients receive the services needed.  Along with the physician they develop a care plan defining strategies and next steps towards achieving desired outcomes and promote client self-determination teaching patients and families the skills necessary to take control of their care with confidence.

Medication Reconciliation: Adverse drug events are one of the leading causes of hospital readmissions.  Patients often receive new medications or have changes made to their existing medications at times of transitions in care.  Community VNA nurses thoroughly review the patients medication regimen comparing discharge medication instructions with medications in the home as well as new or updated scripts. The physician is then called with any questions, clarifications or discrepancies that arise.  The nurse will also assess the patient’s ability or willingness to follow the medication profile.  The nurse may determine that the patient needs their medications pre-poured in order to take them correctly, or needs education on medication uses and side effects and ensures the patient understands any special instructions associated with their medications.

Falls Prevention:  According to STEADI, (CDC’s Stopping Elderly Accidents Deaths and Injury) one out of four older people fall each year with less than half of them telling their family or physician.  In addition, once an older adult falls, it doubles his or her chance of falling again.  One out of every five falls causes a serious injury and is a leading cause of hospital readmissions.  Community VNA’s fall prevention program screens patients for falls risk, assesses modifiable risk factors and intervenes to reduce risk through medication review, home safety management and the provision of therapies to improve balance and strengthen endurance.

Patient Monitoring and Education of Chronic Illness: The staffs of Community VNA are highly skilled in Best Practices and interventions for chronic disease.  They work closely with the patient monitoring essential indicators such as blood pressure, oxygen saturation, pulse, respirations, weight, blood glucose, wound healing as well as others that can provide early signs of potential problems. For patients with CHF, COPD, Diabetes or uncontrolled hypertension CVNA utilizes telehealth technology to support and promote health as well as to enhance care management and patient education.  The staff strives to empower patients utilizing this information to take control of their illness and to develop healthier choices to help prevent hospitalizations.