Visiting Nurse / Hospice Atlanta Blogs

The Four Pillars Philosophy of Preventing Patient Rehospitalizations

By Lynn Adams, RN, BSN

At Visiting Nurse Health System, our mission is to improve the lives of those we serve. We do that by providing care at home, giving patients the security and comfort of recovery in a familiar environment. Helping patients avoid return trips to the hospital is an important way we fulfill our mission.

Asking the Right Questions

About 10 years ago, several employees of Visiting Nurse attended a seminar lead by Dr. Eric Coleman at Atlanta’s Piedmont Hospital. Before this seminar, I had a rough idea about the importance of preventing rehospitalizations, plus some strategies to employ. Dr. Coleman laid it out in an easy-to-remember format – the pillars of the Care Transitions model. I literally wrote down the four steps to make it easy to remember them when meeting a new patient. Now, years later, the Care Transitions model has become part of my practice and the dialog with patients is natural.

Dr. Coleman is a Colorado physician and researcher who pioneered the Care Transitions method and the Four Pillars philosophy. Following Care Transitions helps us provide a better experience when the patient transfers from the hospital or rehab to home.

Over the same 10 years, preventing rehospitalizations has become the focus for not only home health agencies, but for hospitals as well. I’m proud that Visiting Nurse had the foresight to conduct training in this area early. As a home health nurse, when I see each patient, I keep in mind Dr. Coleman’s Four Pillars philosophy to avoid rehospitalizations. By using the Four Pillars, we empower patients and families with the knowledge they need to accomplish their goal of staying safely in their home.

1. Does this patient have all their medications, and a clear understanding of the schedule, dose, and side effects? Hospitals discharge patients with a list of their medications. It’s common for a new medication to be prescribed, but patients may think they should continue with the medications they were on before hospitalization. The initial visit is the time to clear that up.

2. Does the patient have a dependable caregiver who assists with transportation to appointments, and helps with grocery shopping, errands, and hygiene? We talk with the caregiver to measure their willingness and to be sure they know what’s expected of them. Our social workers can also help our patients by finding resources to assist them with these needs.

3. Have I instructed on early warning signs that their illness is worsening? Do they understand these signs? We help caregivers recognize signs of a worsening illness.

4. Have they made all the necessary appointments with their physicians, scheduled within the next two weeks, including specialists? Hospital discharge forms list upcoming appointments. If there are no appointments made, we either have the patient or family make the appointment while we’re in the home, or get their assurance that they’re going to call that day.

Learn more about Visiting Nurse’s home healthcare services when recovering at home.

 

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Happy Nurses Week!
Celebrating this week the incredible dedication, compassion, and resilience of nurses here at Visiting Nurse | Hospice Atlanta and everywhere! 🌟🩺
Nurses are the backbone of healthcare, providing unwavering support and care to patients and their families. In 2025, we continue to recognize the vital role they play in our communities and their commitment to improving lives. Let`s take a moment to express our gratitude and appreciation for these healthcare heroes.

Join us in celebrating Nurses Week by sharing a story of a nurse who has inspired you or by simply saying “thank you” to a nurse who has made a difference in your life.

Thank You For All You Do!! Happy Nurses Week! 💙🏥 #nursesweek2025#healthcareheroes#ThankYouNurses#visitingnursehealthsystem#hospiceatlanta
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Thank you Mutual of America for a great time celebrating our mission, Healthcare Champions, and new friends of Visiting Nurse at Mercedes Stadium.

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Thank you Mutual of America for a great time celebrating our mission, Healthcare Champions, and new friends of Visiting Nurse at Mercedes Stadium.

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We had a great time celebrating OT month, culminating this week with our 2025 Home Health OT Breakfast! 
Thank you OTs for all you do!

#OTMonth #visitingnursehealthsystem #hospiceatlanta #teamworkmakesthedreamwork❤️

We had a great time celebrating OT month, culminating this week with our 2025 Home Health OT Breakfast!
Thank you OTs for all you do!

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Join us for our 3rd Annual Resilience Event on May 17th, 2025.

This FREE event is designed to support those on the grief journey.
Participants will have the opportunity to:
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Together, we can build resilience and support each other through grief. Registration Required.

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Space Is Still Available - Sign Up Today!

Join us for our 3rd Annual Resilience Event on May 17th, 2025.

This FREE event is designed to support those on the grief journey.
Participants will have the opportunity to:
• Hear from others who understand the grief journey.
• Engage in grief break-out groups for shared support.
• Receive tangible tools to cope with loss and grief.
Together, we can build resilience and support each other through grief. Registration Required.

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As we continue to celebrate our volunteers during National Volunteer Appreciation Week & Month, enjoy this message from one of our longtime volunteers and supporters sharing on why folks volunteer!

Barry gives to our community donating his time and talent in many ways impacting many around the globe, including helping individuals on their grief journey through TGBeyond! Thank you for all you do Barry!

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As we continue to celebrate our volunteers during National Volunteer Appreciation Week & Month, enjoy this message from one of our longtime volunteers and supporters sharing on why folks volunteer!

Barry gives to our community donating his time and talent in many ways impacting many around the globe, including helping individuals on their grief journey through TGBeyond! Thank you for all you do Barry!

#volunteer #volunteerappreciation #visitingnursehealthsystem #hospiceatlanta #TGBeyond
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Thank you to all of our Administrative Support Professionals! Celebrating you this week, this month and ALWAYS! You`re support is second to none, we`re grateful for all you do! #support #visitingnursehealthsystem #hospiceatlanta ...

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Go Hawks Beat the Heat Tonight!

Visiting Nurse | Hospice Atlanta celebrates the Hawks players, organization and Foundation for all they do to support our Atlanta community!
Here are some Visiting Nurse | Hospice Atlanta employees and their loved ones, cheering on the Hawks last weekend!
Good luck tonight taking on the Miami Heat!
#GoHawks #visitingnursehealthsystem #hospiceatlanta
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We’re proud to share our President and CEO, Dorothy Davis, joined other Georgia healthcare leaders this week in Washington DC, gathering April 9 for LeadingAge Lobby Day. 
The team meet with both Republican and Democratic representatives to ensure healthcare and choice remain an option for seniors. 
As Visiting Nurse began over 76 years ago, our mission is to improve the lives of those we serve, and we carried the voices of our patients and caregivers to the Georgia representatives. 
We honor this dedicated team of healthcare leaders (Ginny Helms, Deke Cateau, Chris Keysor, Karon Nixon) committed to work in connection directly with local and federal policymakers, to continue helping to drive meaningful change and create a more equitable healthcare system for all. Thank you to these strong leaders, for their unwavering dedication and for being a voice for those who need it most. 
#HealthcareEquality #Advocacy #Leadership #MakingADifference #leadingage #washington #visitingnursehealthsystem

We’re proud to share our President and CEO, Dorothy Davis, joined other Georgia healthcare leaders this week in Washington DC, gathering April 9 for LeadingAge Lobby Day.
The team meet with both Republican and Democratic representatives to ensure healthcare and choice remain an option for seniors.
As Visiting Nurse began over 76 years ago, our mission is to improve the lives of those we serve, and we carried the voices of our patients and caregivers to the Georgia representatives.
We honor this dedicated team of healthcare leaders (Ginny Helms, Deke Cateau, Chris Keysor, Karon Nixon) committed to work in connection directly with local and federal policymakers, to continue helping to drive meaningful change and create a more equitable healthcare system for all. Thank you to these strong leaders, for their unwavering dedication and for being a voice for those who need it most.
#HealthcareEquality #Advocacy #Leadership #MakingADifference #leadingage #washington #visitingnursehealthsystem
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Visiting Nurse Health System is proud to announce that Jacqueline Ralph-Blair was recognized by Modern Healthcare as one of the Leading Women for 2025. This prestigious recognition program acknowledges and honors women executives from all sectors of the healthcare industry for their contributions to care delivery improvement, health equity, policy and gender equity in healthcare leadership. Congratulations Jacqueline!

Please join us in congratulation Jacqueline and enjoy the full press release on our website www.vnhs.org

Visiting Nurse Health System is proud to announce that Jacqueline Ralph-Blair was recognized by Modern Healthcare as one of the Leading Women for 2025. This prestigious recognition program acknowledges and honors women executives from all sectors of the healthcare industry for their contributions to care delivery improvement, health equity, policy and gender equity in healthcare leadership. Congratulations Jacqueline!

Please join us in congratulation Jacqueline and enjoy the full press release on our website www.vnhs.org
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We are thrilled to announce that Regina Ramsey-Dockett has been named Employee of the Month for April 2025! 🎉

Regina's dedication, innovation, and exceptional teamwork have not only driven her success but have also inspired those around her. Her commitment to excellence and her ability to lead with passion have been instrumental to Visiting Nurse for over a decade now!

Please join us in congratulating Regina on this well-deserved recognition. Regina, we are so grateful you choose Visiting Nurse each day! #EmployeeOfTheMonth #TeamSuccess #Congratulations

We are thrilled to announce that Regina Ramsey-Dockett has been named Employee of the Month for April 2025! 🎉

Regina`s dedication, innovation, and exceptional teamwork have not only driven her success but have also inspired those around her. Her commitment to excellence and her ability to lead with passion have been instrumental to Visiting Nurse for over a decade now!

Please join us in congratulating Regina on this well-deserved recognition. Regina, we are so grateful you choose Visiting Nurse each day! #EmployeeOfTheMonth #TeamSuccess #Congratulations
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