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Care Management Home

A new project has a team of health professionals — led by a care-manager "quarterback" — fielding health issues with frail and elderly Humana members, and the results have scored a touchdown for better care.

In Florida, Humana and Pfizer's jointly owned Green Ribbon Health has fielded a Centers for Medicare & Medicaid Services (CMS) demonstration project to manage care for members with diabetes and congestive heart failure. Upon reviewing that demonstration, Humana's team thought a similar model might work well with Humana's senior population.

"It's an exciting endeavor that provides good opportunities for care for members who fit into the frail/elderly, high-risk category," said Anne Jones, Humana's director for Medicare clinical programs and strategy.

Pilot launched in Florida
Humana selected 13 counties in the Florida PFFS and PPO market for the pilot. There, Green Ribbon analytics identified more than 600 of Humana's 8,000 members who could potentially benefit from the program.

Patients qualified for the pilot project by having multiple health conditions as well as needs that would benefit from an in-home assessment. Common problems that cause interruptions of care might include the following:

• depression
• not eating, leading to weakness
• no caregiver to help with transportation to physician appointments
• fall hazards
• medications not organized by time and location, so the patient struggles adhering to the regime prescribed

The home based care management program works as follows:

• The Humana care manager can be described as the quarterback of the care management team. She or he "owns" the case.
• Green Ribbon associates fill the field care manager and community health educator roles.
• The field care manager, who does home visits, is either a nurse or a social worker.
• Community health educators help train caregivers. These lay employees present caregiver classes locally and help develop programs for members or caregivers.
• If a member ends up in the hospital or nursing home, the field care manager is available to visit onsite to see if the member can be returned to his or her home.
• Field care managers also help members plan how they will spend their days. They assist with advanced directives, advanced illness planning, or receiving hospice care — ensuring members' wishes are met, whatever they are.

Sometimes, care managers must link patients with the right external resources. For this reason, the program involves developing an extensive community resource manual for the use of Humana care managers and Green Ribbon staff. Resources include transportation, socialization, meal services, caregiver respite and household help.

"It's a complete program designed to help the member," Jones explained. "If they need only one visit, that's all they get — but they remain in care management with
a Humana care manager who continues to monitor them. If another issue or incident arises, field managers can return. We want to be sure we're meeting members where they are to help them take better care of themselves."

Program expansion planned
The program launched at the beginning of September 2007, and anecdotally, it is very successful.

"We don't have a lot of data yet because it is very early," said Jones. "But members love it. Our leadership is excited, and we're planning to roll out the program in other markets."

In 2008, the program has begun to roll out across the nation in Humana markets, including the rest of Florida, North Carolina, South Carolina, Georgia, Kentucky, Virginia, Pennsylvania, Ohio, Utah, Arizona, Illinois, Wisconsin, New Mexico and Texas. The model is expected to touch 10,000 members by year's end.

Physicians in these markets can refer members to Humana's care management team. Humana staff then will evaluate the member automatically for this more extensive care management model.

"We are really excited about this program because if we can assist these members, we can reduce hospitalizations and ER visits," Jones said. "Most importantly, if we can get them to their physicians in a timely manner, we potentially can avoid spirals of illness."

For more information, contact your local care management department.

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