Schedule of Visits

Home visits are an essential component of the TCM. The TCN must see in order to understand how patients and family/caregivers are managing symptoms, and to determine if the living situation could prove problematic to the patient's health (e.g., the presence of mold in the apartment of a COPD patient; plants that could cause allergies; stressful living conditions). Safety of the patient in completing activities of daily living (ADLs, including bathing, walking, toileting, etc.) and instrumental activities of daily living (IADLs, including shopping, housework, etc.) is assessed, recommendations for adapting the environment are made, and referral to area senior agencies are completed, if needed.

The following visit schedule is utilized under TCM - Patients are visited:

• In the hospital within 24 hours of enrollment;

• Daily throughout the hospitalization;

• In the home within 24-48 hours of discharge from the hospital;

• At least weekly during the first month;

• At least semi-monthly through the duration of the intervention; and

• Additionally, TCNs:

  • Maintain daily telephone availability in order to respond to patients' and caregivers' needs and concerns;

  • Provide patients and caregivers with a written plan with instructions and phone numbers of physicians, local hospitals and ambulance services for emergency care; and

  • Initiate telephone contact with a patient during any week that a patient is not visited at home. The purposes of these calls range from monitoring patient's health status to reinforcing skill acquisition. While the proposed schedule defines minimal expectations, TCNs are instructed to use their clinical judgment to determine the frequency (number) and intensity (length) of patient and caregiver visits and telephone contacts. Preparation for patient contacts may include TCN's consultation with the patient's physician and, for very complex cases members of a multidisciplinary team, to identify strategies to meet patient/caregiver needs.