Using Care Management to avoid unnecessary hospitalizations and Emergency Room visits

Transcription

1 Using Care Management to avoid unnecessary hospitalizations and Emergency Room visits an overview of the Humana Care Manager program Wednesday, June 25, 2014

2 Disclaimer This presentation has been prepared by David Evans, Agency Director of BrightStar Care of Marietta based on observations and experience as a provider of nurses as Care Managers in the Human Cares/Senior Bridge Chronic Care Program. While every effort has been made to accurately portray the programs described herein no reliance should be placed on this presentation. It is based on publically available information and the views and opinions expressed herein do not represent those of SeniorBridge or Humana or BrightStar Franchising, LLC.

3 Humana Chronic Care Program Combines the proven models of Humana Cares and SeniorBridge, a national care management company acquired by Humana. Through HCCP, care managers collaborate with health care providers to help qualifying Humana members follow their physician's plan of care. Through a variety of resources, the program can help members continue to live at home safely while addressing their physical, behavioral, cognitive, social and financial needs. Eligibility and Cost Eligible members are identified based on their disability, comorbidities and chronic care management needs. The Humana Chronic Care Management Program is available to eligible members as part of their benefit plan and at no additional cost. Members can opt out of this program at any time. Services are available for Medicare and commercial members 18 years of age and older who have chronic conditions and medium-to high-acuity caremanagement needs.

4 Overview of the SeniorBridge Programs GOAL: In order to keep patients out of the hospital and avoid unnecessary ER visits, Humana has partnered with SeniorBridge to provide free Care Management to those patients who have been identified as high-risk for hospitalization. Transitions Program The 30 day program consists of three (3) in-person Care Management visits with the patient, coordination with PCP and telephonic contact to ensure adherence to treatment plan. Long Term in-home Care Program - Consists of weekly inperson Care Management visits with the patient, coordination with PCP and telephonic contact to ensure adherence to treatment plan. Assessment with Recommendation a detailed survey of the patient in their home environment and recommendation for future monitoring.

5 Management of the Programs RNs and LPNs are eligible to work in these programs Licensed Social Workers are also eligible for the LTIH program Care management is the objective; there is no skilled nursing, wound care or medication management. Care Managers are sub-contracted or outsourced They are not Humana or SeniorBridge employees Documentation: Care Managers enter all documentation into the secure/confidential electronic medical records of Humana/Senior Bridge (Rosalind) All notes / recommendations are entered into Rosalind and reviewed by the Clinical Team Training: Specific compulsory training in two parts: Web-Ex seminar (offered weekly) Support: Clinical Support Team available 24/7

6 Assessment with Recommendation A Member Survey and Action Plan is a key component of each program but is the primary component of this program to assist the Clinical Support Team to determine eligibility for the Long Term Program (or telephonic support, etc) The 15 page assessment covers: History leading to Referral Background (education, etc.) Living Environment Functional ADLs IADLs Physical Strength / Sleep / Pain Diet & Nutrition Medical Diagnosis and History Medication Administration & medications Psycho-social Service Goals Financial / Legal Action Plan

7 Transitions Care Management Program GOAL: To keep high-risk members out of the hospital and ER PROGRAM: SeniorBridge provides Care Management for 30 days after hospital or sub-acute discharge, at no cost to these members. Three (3) in-person Care Management visits with the member, coordination with PCP and telephonic contact to ensure adherence to treatment plan. PROCESS: A referral is made to SeniorBridge from a Humana Onsite nurse. SeniorBridge assigns a Care Manager (CM). CM contacts patient within 24 hours to explain the Transitions Program; and to schedule first in visit in the hospital and second visit in home within 48 hours of discharge from hospital. If member can not to be seen in hospital, all 3 visits will occur in member s home. If member agrees to enroll in the Program, a simple consent form is signed at the first visit. CM completes the Member Survey in members home CM coordinates/helps schedule an appointment for patient to see PCP within one week of discharge. CM will assist member and/or family member to connect with other needed resources such as meals, DME, transportation, pharmacy assistance and other financial and community resources. CM performs medication reconciliation to ensure that all prescribed medications are in the home. CM provides care coordination and makes periodic telephone calls to patient during the 30-day period to ensure adherence to treatment plan and reinforce red flag indicators for re-hospitalization. CM is available to answer questions from patient/family during the 30 day period OUTCOMES AT 30 DAYS: Patient will have the means to obtain medications, understand what medications to take and how to take them. Patient will understand self-care requirements and be able to implement them. Patient will have access to helpful resources if needed. Patient will be able to remain at home and avoid unnecessary hospitalizations.

8 Long-Term In-Home Care Management Program GOALS: To reduce unnecessary hospitalizations and emergency room visits. Improve access for members most in need. Improve quality of care and outcomes for members with chronic illness. Improve cost savings for Humana. PROGRAM: Care Managers (CM) act as advocates and coordinators to help members access benefits and resources and as coaches to assist with disease management, self-care, medication reconciliation, and identification of gaps or barriers to care (but do not provide direct care). PROCESS: A referral is made based on qualifying criteria that might include: Three (3) hospital admissions in the last year. Claims Based Analytics (CBA) score greater than 65,000. Other entry points into the program including New Member Predictive Model (NMPM), Probability of Repeated Admissions (PraTM), Vulnerable Elders Survey-13 (VES-13), or based on clinical judgment. Humana Cares/SeniorBridge assigns a Field Care Manager (FCM). FCM contacts the member within 24 hours to explain the Long-Term In-Home Care Management Program and to schedule the first visit. If the FCM is unable to contact the member, the member declines participation in the program, or the member cancels a scheduled visit, an activity note is documented. At the first home visit, the FCM provides a welcome packet, obtains the member s consent to enroll in the program, begins the Member Survey and schedules a weekly face-to-face visit. FCM completes the Member Survey and Action Plan within 10 days of the first home visit. FCM continues to visit the member weekly and to document any events within 24 hours. If the member is hospitalized, the FCM will continue to see the member on a weekly basis to facilitate a safe discharge and transition back to the member s home and then visit the member in the home within 48 hours of discharge. As the member s needs change, services will be modified to meet an appropriate level of care.

9 A Case Study in Care Management Narrative from Jennifer, LPN SeniorBridge Care Manager in Humana LTC program This is a description of 1/[2] of the 15cases Jennifer is currently managing. I have two patients in Rome that are husband and wife. I began my Care Management visits in December 2012 for Octavia who had lung cancer. Julius had been diagnosed with colon cancer and, at my recommendation, he was also added to the program after about two months. Between them they have multiple chronic medical conditions including diabetes, COPD, chronic pain, arthritis, cancer and both are fall risks. Both had been in and out of hospital numerous times. This was mainly due to their lack of knowledge of their disease processes. Many times they would skip appointments or miss medications due to lack of funds. They live at home with their daughter who has medical issues of her own and is currently disabled. I monitor their appointments and medications. I helped them to find resources to assist with their medication expenses so that they would be able to follow the treatments their doctors had prescribed. I also assisted them with finding resources to help make their home safer with grab bars and raised toilet seats in the bathroom, which is where most of their falls occurred. At some point the cancer drugs caused sudden and rapid tooth decay and Julius had to have all of his teeth extracted; I helped him find affordable dentures. The Community Resource Directory is particularly helpful in identifying appropriate resources. Both patients struggle at times but, with persistence they follow their prescribed treatment, as ordered. I continue to monitor them weekly for any complications or difficulties, As of now Julius cancer has gone into remission and Octavia has been diagnosed cancer free.

10 Summary We have been engaged in this program for 18 months now, almost since its inception. It has been growing rapidly and evolving as it goes. Our nurses really love their roles as Care Managers. They love the continuing patient contact. They truly believe that this is helping them improve their patients quality of life and health outcomes. Patients form a tight bond with their Care Managers and value their guidance, experience and knowledge. We can see that it is helping to manage costs of health delivery. The growth of admissions into the program demonstrates the power it has to control costs for Humana. We are proud to be a provider and a partner of SeniorBridge and, through them, Humana in these programs.

11 Thank you for your time Questions?