Open Forum

We do post discharge follow-up as well as chronic disease management (CDM). I've attached some screen shots of our post DC template using a test patient (so not everything will be filled out). Important to note that a post DC follow-up should be more than just a regurgitation of the DC instructions but rather verifying if the patient understands them and re-educate them if needed as well as provide any follow-up interventions. Often the provider DC instructions are very basic and not always patient centric. For example, diabetic patient discharged on regular diet or vague activity order and the patient has specific needs.

Our HTN CDM template, also attached, it's extensive but can be tailored to the purpose of the encounter. In the screenshots, the purpose selected was for scheduled RN HTN initial visit but alternatively it could be provider requested, interval follow-up, etc. Due to size, not all the language could be included in the screen shots but I think you get the idea. HTN is the only one we have complete. We started working on the DM CDM template a couple of weeks ago but it will look similar to the HTN; same for HF, COPD, etc.

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Courtney A. Monterusso BSN, RN, FNS

Performance Improvement Facilitator –Primary Care Nursing  ONS CPP PC Field Advisory Products

Past Chair (2021-2022), Veterans Affairs Special Interest Group, AAACN    Click here to learn more!                                    

VA St. Louis Health Care System | 915 N. Grand Ave, St. Louis, MO 63106 

314.652.4100 ext. 54396 or 289-7676  11F/JC  courtney.monterusso@va.gov

Get a tour of the VA through the C20 Program, check it out!  C20 Landing Page

"There is no limit to the amount of

good you  can do if you don't care

who gets the credit."

                             ~Ronald Reagan~

There is actually for the VA, a distinction between using telehealth platforms and a formal Home Telehealth program. At times, the staff for the home telehealth program may be assigned to the Primary Care areas, but this is not the case for our facility. So, primary care uses the Patient Aligned Care Team (PACT) model to deliver care, which is similar to the patient-centered medical home model. Services are similar to other primary care provider teams, but we also utilize other platforms, such as care over the phone and via video visit. RNs are required to follow-up post discharge and provide chronic disease management but also provide immunizations, in-clinic procedures, etc. Our Home Telehealth is a national program with its own policies, procedures, education/training, and monitoring. As I stated, our local home telehealth staff do not report to primary care but are embedded in all our primary care outpatient clinics. The home telehealth staff provide remote monitoring for chronic diseases, education/coaching, and often huddle with the PC teams. The home telehealth program does have a high intensity and low intensity programs; high intensity is intended to assist patient achieve an optimal/stable status but is not necessarily long term. Low intensity is the path to assist patient keep goals, such as weight loss. Since the start of the pandemic, the home telehealth staff have also monitored COVID positive patients until follow-up is discontinued and returned to the provider. The home telehealth program utilizes national templates; what I provided is what we have developed locally for our PC RNs. The VA is still working their way towards developing national templates...

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Courtney A. Monterusso BSN, RN, FNS

Performance Improvement Facilitator –Primary Care Nursing  ONS CPP PC Field Advisory Products

Past Chair (2021-2022), Veterans Affairs Special Interest Group, AAACN    Click here to learn more!                                    

VA St. Louis Health Care System | 915 N. Grand Ave, St. Louis, MO 63106 

314.652.4100 ext. 54396 or 289-7676  11F/JC  courtney.monterusso@va.gov

Get a tour of the VA through the C20 Program, check it out!  C20 Landing Page

"There is no limit to the amount of

good you  can do if you don't care

who gets the credit."

                             ~Ronald Reagan~