Transitioning from a Hospital or Skilled Nursing Facility to Home.

SC House Calls provides nurse practitioners (NP’s) who follow patients in their homes after being in hospitals and skilled nursing facilities (SNF). Our NPs will assess and order medication and labs as necessary and will send summaries of their visits directly to the patient’s primary care providers.  Patients are encouraged to follow up with their Primary Care Provider (PCP) while on our services and in no way does our service conflict with a patient’s ability to see other doctors.  Our protocols for visits are based on risk assessment scores of patients to determine the number of in-home visits that will reduce possible hospital readmissions.

Over 40% of all patients discharged from home health after a hospital or SNF stay will be re-admitted to an institutional setting within 30 days of discharge from home health.  Our home Base model of patient care after an institutional care stay consists of following the patient for 90 days post-discharge or 30 days post home healthcare discharge whichever is longer.

Our program works alongside home health.  Home health providers are not practitioners and therefore, cannot write orders for labs or medications.  A patient, to qualify for home health, must be consistently homebound and unable to go out of the home on their own and yet are expected to get back and forth to a physician’s office.  In 2019 Medicare said that providers are not under the same restrictions and limitations of home health and are now allowed to see any patient in their home if that is the patient’s preference (not only when homebound).

Medicare recommendations based on risk assessment scores assume a patient is being seen regularly by a practitioner.  In a hospital setting the standard of care for physicians is to see patients every day. In a skilled nursing and rehabilitation setting, patients are seen on average, 3-4 times a week. In assisted living, patients are seen on average 2-4 times a month. And yet we send people home after hospitalization, and they see there PCP once a month (if that).

Our Model of Nurse Practitioner home visits:

  • NP visits the patient in the hospital or Skilled Nursing Facility (SNF) before discharge.
  • NP visits in the home within 72 hours of discharge
  • NP visits at least weekly for the first 30 days.
  • NP visits at least twice a month through 90 days post-discharge or 30 days post home health discharge or as long as they are homebound.
  • SC House Calls has a 24/7 call center that is staffed by a nurse and Nurse practitioner who can take calls and sign orders.

Contact us today to learn more about this new and innovative program.