Objective: To describe nursing and social work cross-discipline efforts to improve patient care and adherence to treatment plans as part of an interdisciplinary home visit program for Parkinson’s disease (PD), and examine areas where further education and intervention is needed.

Background: The Edmond J. Safra Interdisciplinary Home Visit Program (HVP) provides comprehensive care to homebound individuals with advanced PD. Visits include multi-discipline evaluations and treatment plans. Research has demonstrated the importance of social work and nurse intervention for both patients and families. Interim analyses of the HVP found that patients do not consistently follow through with referrals, recommendations, and medication changes made during visits. This can disrupt continuity of care and negatively impact patient health and well-being. To address this gap in care, the HVP nurse and social worker initiated continuity calls between visits to improve adherence to recommendations.

Methods: HVP patients receive 4 home visits over 12 months. Each visit entails an evaluation by a movement disorders neurologist, social worker, and nurse, including examination, medication reconciliation, psychosocial evaluation, and referral to in-home services. Continuity calls are made by the HVP social worker or nurse 2 weeks after each visit to review recommendations and referrals.

Results: The social worker and nurse made 55 HVP continuity calls in a 4 month period, with a response rate of 87.3%. Average time spent on a call was 14.5 minutes. The most discussed topics were: medications (83.67%); Parkinson’s symptoms (59.18%); allied health interventions/referrals (55.10%); home care (32.65%); psychotherapy/support groups (28.57%). Education and supportive counseling was provided on most phone calls. Analysis of time offset by continuity calls is underway.

Conclusions: The HVP provides continuity of care to a vulnerable, diverse cohort of PD patients. After visits, patients and families require further clarification on treatment plans. Nursing and social work collaboration in initiating continuity calls creates an opportunity for patients to receive ongoing education and counseling for their persisting nursing and psychosocial needs. Continuity calls improve patient care, and potentially saves time spent communicating with patients between home visits.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/the-value-of-follow-up-the-role-of-social-work-and-nursing-calls-in-an-interdisciplinary-home-visit-program-for-advanced-parkinsons-disease-patients/