老年人护理 & 服务

不，病人不需要呆在家里看老年人上门服务提供者. 然而，病人应该, 有一个功能或认知上的限制，使去办公室旅行变得困难.

老年人家庭电话转介是通过患者的主要提供者办公室, 青年医院免预约或青年医院急诊科. 老年人上门服务提供者将为患者进行一次访问.  在某些情况下，对急性医疗问题进行短期随访. Evaluation 和 treatment notes are completed in eCW 和 will be forwarded to the patient’s primary care provider. 如果要求或认为有必要根据临床印象, the House Calls provider may reach out to the provider office via phone call during or after a home visit to coordinate the patient’s plan of care. Ongoing follow up should be provided by the patient’s primary care office 和 the patient should continue to see their primary care provider for regular visits.

上门服务的推荐可以通过eCW进行，使用外发推荐功能.  推荐信应包括请求访问的原因, 有关患者的相关背景信息, 如果知道护理目标, 以及家里已知的安全隐患. 推荐应直接分配给艾琳摩根AGPCNP.

Phone calls 和 telephone encounters to provide additional information are always welcome 和 can be helpful to start the process of setting up a house call.  然而, a referral into eCW is also required as this is used for tracking purposes 和 helps to ensure all referrals are addressed.

一旦收到推荐, 老年人上门服务提供者将在1个工作日内与患者联系, 病人出诊通常会在1-2个工作日内安排. Time 和 date of the visit will be documented within the referral for reference 和 tracking purposes. 一旦看到病人, 将在eCW中记录一份说明，然后转发给初级保健提供者. Any additional follow up or care coordination required will be communicated with the primary care office.

急性精神病发作不属于出诊计划的范围. 也, the need for a house call visit should not be based solely on the availability of transportation or weather related challenges. 作为病人护理计划的一部分，化验结果可以在就诊时收集, 只要评估也在进行，并且访问不仅仅是为了实验室收集.

Vaccines could be given as part of a visit if the House Calls provider is already seeing the patient for another reason. 上门服务提供者不能仅仅为了接种疫苗而出诊.

是的, 上门服务提供者可以看到VNA正在跟踪的病人, as long as there is a specific need identified for advanced practice provider involvement in addition to the VNA.

具体情况具体分析, it may be appropriate for the House Calls provider to make a visit to see a patient for a follow up visit following a discharge from the hospital.  The case manager at the primary practice or primary care provider can reach out to the House Calls nurse practitioner to discuss these types of visits.

The Older Adult House Calls line phone number is answered by a care access representative in the YH 护理访问 Center. 如果病人有公开转诊到出诊项目, 护理访问代表将协助患者安排家访预约. 如果没有公开转诊, the patient will be directed to their primary care office to discuss their symptoms 和 determine if a house call is appropriate to meet their needs.