Home visits help reduce Medicare readmissions

Nurses educate patients, link them with resources

A program that provides at least one home visit for members who qualify for case management has helped Blue Cross Blue Shield of Arizona Advantage drop its all-cause readmission rate for all ages to 13%.

The program is a joint venture of Banner Health and Blue Cross Blue Shield of Arizona Advantage and serves members in the Maricopa County area. "The goal of the program is not just to reduce readmissions but to assist our members in obtaining the services they need and to provide case management in the community," says Mary Hickie, RN, case management services director for Blue Cross Blue Shield of Arizona Advantage.

The program receives referrals from physicians, home health nurses, and case managers in the acute care hospitals and skilled nursing facilities. Family members and caregivers refer patients, and some members self-refer.

"We are the last stop for people in the community. We step in when home health is no longer visiting and they aren't ready for hospice but they still need care coordination. Our goal is to provide at least one home visit for every individual we identify for case management," Hickie says.

Members who qualify for the case management program have experienced strokes or myocardial infarctions or have chronic conditions, such as chronic obstructive pulmonary disease, heart failure, or cardiovascular conditions.

"We work hard to identify those conditions that may be at more risk for readmissions," she says. "We zero in on patients with diagnoses that make them likely to be readmitted." For instance, patients with chronic obstructive pulmonary disorder have an average of six comorbidities and often need a lot of assistance to stay out of the hospital, she says.

"We make an effort to identify as many of them as possible and to provide standardized education and outreach," she says. The case managers assist patients in getting financial assistance if they qualify.

The health plan also includes patients in the program who have been treated for falls in the emergency department or admitted to the hospital because of fractures caused by falling. They conduct a home assessment, evaluate the patients' functional status in the home, and check for safety issues.

Members have the opportunity to opt out of the program, but if the case manager feels strongly that the member would benefit from assistance, he or she asks the patient's primary care physician to recommend the program.

When eligible patients are discharged from the hospital, the case manager makes a call within three days to address questions and concerns, ensures that the member has a follow-up physician visit, makes sure the new prescriptions have been filled, and conducts medication reconciliation.

Case managers carry a caseload of 70 to 75 members in varying stages of case management. The frequency and types of interventions depend on the member's needs. In some instances, the case manager assesses the member in the home and follows up by telephone. Other times, the case manager may feel that the member needs additional home visits. In some cases, the case manager may conduct an assessment over the telephone and determine that a home visit is not necessary if the member understands the medication regime and treatment plan, and knows to follow up with his or her physician.

Case managers spend an average of one to one-and-a-half hours in the home talking with patients and family members and assessing what is going on in their lives. The case managers may follow up by telephone or make another home visit, depending on what they determine the patient needs.

"Visiting the home helps us get a better idea of what is going on. Many times patients tell us over the phone that they are doing great, but when we get into the home setting, we may find that there's no food in the refrigerator or that all of their medications are in a bowl in the middle of the table," she adds.

Case managers follow the members in the program for an average of three to nine months, but some have been in the program for six years or longer. One case manager followed a member at home, visiting once a month, until the woman was moved to a long-term care facility. The case manager now works with the spouse and is guiding him as he gets his wife into hospice.

The case managers also visit members in skilled nursing facilities and assisted living centers to coordinate care with the staff. They visit members in the hospital and coordinate care with the hospital social worker or case manager.

The program also provides educational programs to help members manage their conditions and helps them access community resources such as support groups, financial assistance organizations, long-term care planning, and education on advance directives and hospice options, when appropriate.

"We are looking at the entire paradigm of health and wellness. Our goal is not specifically to reduce readmissions but to make sure members get the right care at the right time and in the right place. We want our members to establish ongoing, consistent care with their physicians to improve the quality of care and avoid hospitalizations and emergency department visits," she says.

The case managers meet monthly at the Banner Alzheimer's Institute for guidance on how they can help families whose loved ones have behavioral issues. "It's been helpful for us to have people with expertise to share," she says. "Our program focuses on the full continuum of care, and we share information and coordinate care at all levels of care."

The nurses meet twice monthly with representatives from the Banner Home Care Agency to share information, brainstorm on ideas for managing the care of members and discuss ways to improve the transition process.

"Sharing information reduces the situations when we ask patients the same questions over and over and improves the care coordination process. The home health nurses, case managers, and therapists all call each other when they have questions. This very good relationship benefits our members," she says.