An IHC Advanced Practice Nurse (APN) works with selected Thresholds outreach teams and attends Thresholds team meetings at regular intervals. Members who could benefit from house calls are identified thought a collaborative effort between the Thresholds and IHC staff. Members may be identified during team meetings, referred by a Thresholds Community Support Specialist, or referred by IHC clinic staff as a resulf of missing many clinic appointments. Eligibility criteria include a member’s need for a primary care provider, inability or unwillingness to come to the IHC clinic, a willingness to be an active participant in care, and living in a safe environment for the delivery of primary care service. Initial visits are performed jointly with Thresholds staff and the WOW APN and continue until thr member is willing to participate in group or individual clinic visits.
IN the first year, the WOW APN provided house calls to 48 members on 12 Thresholds teams. The APN performs a physical examination of the member often over the course of 3 visits in which she collects vital signs and weights, collects lab specimens and conducts a physical assessment. The APN formulates a treatment plan that often requires weekly follow-up visits to explain the lab results and diagnoses. Provide health education, and coordinate referrals for additional diagnostic testing either at the IHC clinics or local hospitals. In one of the more serious situations of a member refusing primary care many years, the APN identified a probable breast cancer and worked with the Thresholds