A structured home visit program by non-licensed healthcare personnel can make a difference in the management and readmission of heart failure patients

The purpose of this observational study is to evaluate the effectiveness of structured home visits by non-licensed healthcare personnel (NLHP) on the patient’s adherence to a medication plan, dietary restrictions, and knowledge about when to seek care. This descriptive, qualitative study evaluates the Grand-Aide ® program that aids in the management of heart failure patients across the continuum of care using NLHP. Patients are offered enrollment in the program starting the day following hospital discharge. Visit frequency is high immediately after discharge and lessens over time as the patient’s health knowledge and condition improve. During the visits, NLHP record vital signs including weight, ask the patient protocol questions in a Yes/No format, record and report responses to the supervising Nurse Practitioner, reinforce discharge teaching, and review medications. Preliminary findings from this project provide information about issues found while providing home-visiting services to patients with heart failure. Early recognition of these issues allows for early treatment or correction, preventing further deterioration that could lead to readmission. Programs like this can be an integral part of the health care system that manages patient’s care across the continuum, with intensive focus immediately after hospital discharge.