Home visits give support for at-risk members

Members need extra psychosocial support

When members in UPMC Health Plan's Special Needs Plan are experiencing excessive hospital admissions and/or emergency department visits, the health plan sends a team of social workers and nurses to their homes to assess the members' healthcare and psychosocial needs and get them the resources they need to stabilize their conditions.

Members targeted for the home visits are difficult to engage and need high-touch interventions. Many of them have social and/or behavioral issues or drug and alcohol abuse issues, according Deb Smyers, RN, BSN, senior director of program development for the Pittsburgh, PA-based health plan.

"They need a lot of psychosocial support from community organizations," she says. "Some live in poor housing conditions and have difficulty getting out because they have trouble navigating stairs. We have helped patients find housing and access housing assistance funds."

UPMC Health Plan's Special Needs Plan has 16,000 members enrolled. Almost 60% of these members are disabled and under the age of 65. Many of the members have multiple chronic conditions. More than one-third of members under age 65 have a serious mental illness. "Managing the health care burden of this population is a challenge," Smyers says.

The team assesses the members' living situations and helps them access whatever community resources they need. They check the cupboards and refrigerators to make sure that there is enough food in the house and assess the member's ability to manage their activities of daily living. They link members to community services such as light housekeeping services and Meals on Wheels if the members can't manage alone and don't have family support.

"By going into the homes, the team can build a relationship with the members and get a true picture of members' needs," Smyers says. "Then they do whatever is necessary to get the members stable and connected to their primary care provider."

The clinicians conduct medication assessment and educate patients on the importance of following their medication regimen.

Some of the members don't understand the benefits. For instance, they don't know that they can go to a physical therapist or other specialist. The team helps them get connected to services they need.

If the patients have a co-pay and have trouble paying it, the team calls in a pharmacist to conduct medication review and talk to the physician about changing medications. If the medication regimen is too complicated for the patient to follow, the pharmacist will talk to the physician about managing medication in a different way.

The clinicians help members create an emergency response plan that includes details on what to do when they experience symptoms, when to call the physician, and when to go to the emergency department.

The team continues the home visits for several months until the patient is stable, then hands the patient over to another health plan case manager for additional case management or disease management by telephone.