Protocol 4-749 - General Home Visit

CMH EMS & MIH Protocols

EMT w/CHW:

• Program admission requirements: Note, an initial, one-time assessment visit may be conducted prior to official admission into the MIH program.
• Must be under the care of a CMH physician with an active medical record in CMH's electronic medical records system.
• Must have a pre-designated discharge date from the program no greater than 90 days from admission.
• Services provided by CMH MIH must not be otherwise available through other mechanisms or programs.
• Consent forms must be signed by the patient or their guardian.
• Program discharge triggers:
• Unsafe environment for personnel.
• The patient requests discharge from the program.
• The pre-designated discharge date has been reached.
• Cancellation or missing at least three (3) appointments.
• Patient non-adherence to goals or aggressive behavior.
• Patient relocation out of CMH's region.
• Patient becomes incarcerated, jailed, homeless, or other situation where visiting in a home is not possible.
• Flow of home visit:
• Contact the patient prior to the visit by phone or in person to verify appointment date/time and location. If the patient is a referral from in-patient admission or emergency room visit, attempt to see the patient in-person prior to discharge and include a face-to-face report from the physician.
• Review available patient records prior to home visit. These records should include accessible systems such as CMH Expanse and CMH ESO at a minimum before each visit.
• Print and have the patient sign the universal consent form on every initial visit.
• Vehicles driven to home visits by MIH staff shall be marked with "CMH Mobile Integrated Healthcare" and shall not be an ambulance. MIH personnel will also be wearing an MIH uniform with a CMH photo ID badge.
• Home visits shall not occur at the time of the patient's request for an ambulance or calling 9-1-1. If referral to MIH is made from an ambulance, a separate visit shall be scheduled at a different time.
• Ensure personnel safety.
• If at any time, the patient is presenting sign or symptoms that require ambulance transport or treatment by an emergency room physician, contact 9-1-1 to make an ambulance request. Consider maintaining patient care throughout transport. In all cases, contact the emergency room physician to provide a verbal report.
• Ensure patient privacy.
• Obtain applicable consent signatures.
• Refer to Protocol 4-708 - General History and Physical Exam as applicable.
• Refer to Protocol 4-833 - General Medications Reconciliation as applicable.
• Refer to Protocol 4-916 - General Safety Assessment as applicable.
• Refer to Protocol 4-957 - General Social Assessment as applicable.
• Refer to and follow standing order protocols and on-line physician orders.
• Consider contacting the patient's Primary Care Provider (PCP) as needed for orders or consultation outside standing orders.
• Work with the patient to develop or modify the care plan with SMART objectives for the next visit.
• Make all efforts to refer needs to existing agencies and do not duplicate services. Assist the patient in enrolling in applicable services.
• Refer to CMH Policy CLN03-02 - Clinic Referral.
• Refer to CMH Policy HHA09-17 - Referral Criteria for Other Skilled Disciplines, Dietitian, and/or Diabetic Educator.
• Refer to CMH Policy HHA09-31 - Social Service Referral.
• Refer to CMH Policy HHA23-02 - Hospice Referral and Admission Procedure.
• Refer to CMH Policy MSI25-01 - Sleep Institute Referral Appointments.
• Refer to CMH Policy RS02-01 - Rehabilitation Referrals/Orders.
• Refer to CMH Policy SS03-02 - Skilled Nursing Facility Referral.
• Refer to CMH Policy SS03-04 - Residential Care Facility Referral.
• Refer to CMH Policy SS03-08 - Community Agency Referral.
• Refer to CMH Policy SS03-09 - Home Medical Equipment (HME) Referrals.
• Refer to CMH Policy SS03-11 - Hospice Consultation/Referral.
• Refer to CMH Policy SS03-12 - Home Care Services Referral.
• Refer to CMH Policy SS04-05 - Hearing and Visual Referral List.
• Refer to CMH Policy SS07-01 - Referral of Psychiatric and Behavioral Health Patients.
• Patient and caregiver education must be a high priority including teach-back to ensure understanding.
• Schedule the next visit as applicable. Typical schedules are one visit per week.
• Schedule follow-up appointments with the PCP and/or other services as needed.
• Refer the patient to the Red, Yellow, and Green zones for their specific condition and respond accordingly before their next scheduled visit.
• Documentation:
• Complete an ePCR in ESO for the initial visit. Fax the completed ESO record to the referring agency HIPAA-compliant number for inclusion in their medical record system.
• If the patient exists in CMH medical records, document the visit in Expanse.
• Minimum documentation for every visit includes:
• The patient's medical needs.
• "CP (or CHW) will continue with the discharge plan."
• "Patient will follow up with the PCP if necessary or approrpiate."
• Intended return visit plan with weekly/bi-weekly/etc. assessments.
• "Home medications were reconciled. The patient is able to afford and obtain their medications. The patient understands what medications are for and they will take them consistently as prescribed." Add any issues identified and resolved.
• "The patient has adequate transportation to all necessary healthcare-related appointments." Add any issues identified and resolved.
• "Financial burdens were discussed along with opportunities to resolve issues." Add any issues identified and resolved.
• "Potential legal situations were discussed along with opportunities to resolve issues." Add any issues identified and resolved.
• "Communications barriers regarding healtchare were discussed along with opportunities to resolve issues." Add any issues identified and resolved.
• "Social issues that may present barriers to the patient's healthcare were discussied along with opportunities to resolve issues." Add any issues identified and resolved.

AEMT w/CHW:

• Ensure completion of applicable items above.

RN w/CHW:

• Ensure completion of all applicable items above.

Medic w/CHW:

• Ensure completion of all applicable items above.

CP:

• Ensure completion of all applicable items above.

CMH Pre-Hospital Services Mission: "Provide safe, exceptional, and compassionate care to our communities with an emphasis on highly trained and empowered staff."

CMH Mobile Integrated Healthcare Mission: "Provide exceptional, compassionate, and patient-centered care by a mobile collaborative team to improve patient experience, improve quality outcomes, and reduce healthcare costs."

Polk, Hickory, Cedar, & St Clair County EMS Protocols is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.