Visit the high risk patient in the hospital or skilled nursing facility before discharge and contact the patient within 24 hours of discharge form the hospital.

If at any time the patient requires medical treatment, the home health nurse will contact the Primary Care Physician and obtain medical orders.

Provide follow-up care for 3 weeks after the assessment visit, either by a visit if the patient is receiving home health care or by telephone if the patient has not met the criteria for home health care.

Comprehensive assessment on the first visit and plan follow-up care as needed. Emphasis on:

• Use an integrated approach to assess each patient at risk for readmission

• Perform a comprehensive risk assessment with disease specific indicators

• Incorporate self-management tools into daily practice

• Reconcile medications and customize a Medication Action Plan

• Monitor and manage the use of medication at all times

• Activate fall prevention plan based on multi-factorial fall risk assessment

• Assess and evaluate functional status and ability to safely remain at home.

• Promote follow-up with physicians within 7 to 10 days post discharge

• Educate on identification of signs and symptoms of disease exacerbation

• Assist the patient to maintain a Personal Health record

• Conducts standardized Depression screening every visits

• Assess health literacy

• Administer pneumonia vaccine as indicated

• Improve communication agency wise related to patient high risk status