Why Clinical Surveillance Matters Between Office Visits

For many older adults, the greatest clinical risk is not always visible during an office visit.

The chart may show the diagnoses, medications, labs, and treatment plan. But what happens
after the patient returns home can be very different.

A home-based medication review of older adults found that 94.4% had at least one discrepancy
between medications documented by the primary care physician and medications actually
being used at home.

Patients averaged 2.8 undocumented medications, and 53.9% were taking at least one undocumented medication associated with high hospitalization risk. (Köberlein-Neu et al., 2018, Research in Social and Administrative Pharmacy)

That is more than a medication problem. It is a visibility problem.

A patient may misunderstand instructions, take an old prescription, skip a new
medication, use the wrong dose, or depend on a caregiver who cannot reliably manage the regimen.

And medications are only one example.

Clinical status can also change between visits through worsening edema, shortness
of breath, blood pressure or glucose instability, cognitive change, poor intake, or
increasing weakness.

These changes may begin before the patient reaches the threshold for an office call, ED visit, or hospitalization.

That is the gap clinical surveillance is designed to fill.

Home health nursing provides repeated observation in the environment where the
treatment plan is actually being carried out. The nurse can compare the plan in the
chart with what the patient is doing, identify emerging changes, assess whether the
patient or caregiver can safely manage the regimen, and communicate meaningful
findings back to the physician.

For the right senior, this creates an additional layer of clinical visibility between office visits.

The chart shows the documented trajectory. Clinical surveillance helps reveal what
is happening between visits.

Download PDF