There are four main objectives that Lisa and her fellow VNA nurses focus on with their HPP patients. Number one is attaining their patients’ goals. “We often address their goals in relation to their diagnosis and prognosis,” says Lisa, who has been a registered nurse since 1996.
The second objective is medication management, which is particularly important for patients recently released from a hospital. “There’s often a medication discrepancy; they have one medication at the hospital and a different one at home,” says Lisa.
The third objective is timely follow-up, within 7-10 days, with a patient’s primary care physician (PCP) and specialists to coordinate the patient’s care.
The fourth and final objective is patient centered education and coaching. “Patients may forget or may not understand their disease processes well. I give them robust teaching on that and ways that they can prevent exacerbations of those diseases to help avoid unnecessary hospitalization.