Seamless system refers members to services

Referrals come from a variety of sources

Referrals to Humana’s Personal Nurse program come from surgical authorizations, hospital authorization or claims data, customer service, providers, and the members themselves.

One of the key components of the program is creating an integrated system that appears seamless to the members, says Jackie Willmot, RN, MSN, MBA, director of clinical interventions at Humana.

When a member calls Humana through its triage line or through the new member specialist line, if the need for a personal nurse is identified, that member is transferred directly to a personal nurse.

"In addition," Willmot says, "we are building electronic bridges for our information so that when we gather information on the first call it is transferred with the call so that the Personal Nurse has that information immediately and the member doesn’t have to walk through and repeat all the information again with another individual.

"Before we had this service, members might call trying to understand their benefits or identify community resources and may have contacted several departments for information. Then when they got off the telephone, they felt like they didn’t have an answer. With Personal Nurse, when we identify a member with a complex clinical need, we give them one place to call," she concludes.

If members have a question about explanation of benefits, the Personal Nurse can help them understand and can walk them through learning to look up their benefits on the Internet site.

If it’s a complex issue, the nurses can refer the member to the right person in the benefits or claims departments.

"The goal of the personal nurse is not to show them the way but to help them find the way," Willmot says.

The Personal Nurses are notified when a member is approved for hospitalization as well as when they are actually admitted to the hospital. Some of the referrals come from the providers even when hospitalization is not needed, such as members who have a chronic illness and need some assistance.

"We have a close relationship with the provider community in all our markets. They know about the Personal Nurse service and can refer members if needed," Willmot says.