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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🏌️‍♀️ We’re proud to be part of a great cause on and off the course!

Visiting Nurse Health System | Hospice Atlanta was honored to participate in and sponsor this year's LeadingAge Georgia Golf Tournament—an event that brings together healthcare partners and changemakers in senior care. 

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🎉 Please join us in celebrating our Employee of the Month – Dykia Brummitt! 🌟

Dykia’s dedication, compassion, and positive team spirit make a lasting impact on everyone she cares for. Her commitment to our mission and values here at Visiting Nurse Health System shines through in all she does, and we are so grateful to have her on our team. 💙👏

Congratulations, Dykia—you truly embody what it means to provide care with heart! 🏆

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🎉 Celebrating Nurses Month continues with our incredible nursing team at Hospice Atlanta | Visiting Nurse Home Health! 💙🩺Here's our Home Health team celebrating this week! We’re so proud of our compassionate, dedicated nurses who go above and beyond every day to care for our community in the comfort of their home. Thank you for all that you do! 👏

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We want to extend our heartfelt thanks to everyone who joined us last Saturday for Hospice Atlanta's 3rd Annual Resilience bereavement event. Whether you came to listen, speak, or simply be present, your participation helped create a space of healing, support, and strength.

A special thank you to our incredible speakers, who so generously shared their stories, insights, and compassion. Your words touched many and reminded us all that even in grief, we are not alone.

To every attendee — your presence was powerful. Thank you for showing up for yourselves, and for each other. Together, we honored our losses and found comfort in community. Thank you to our gracious volunteers and staff who supported the event operations. Let’s continue to walk this path together. 💛

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💐Happy Mother's Day!💐

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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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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:
• Hear from others who understand the grief journey.
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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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