Improving care transitions and chronic care

According to most national studies, about 18 to 20% of patients discharged from hospitals are readmitted within 30 days. A 2013 report by the Dartmouth Atlas Project characterized the problem as “a chronic malady” and called it “revolving door syndrome.”

Some readmissions can’t be helped, of course, but many can and should be prevented. In fact, in 2013 the Centers for Medicare & Medicaid Services identified this as one of the biggest problems the U.S. healthcare system faces, and set the annual cost of unnecessary readmissions at $17 billion for Medicare patients alone.

For the past few years, Humana at Home has focused on finding ways to better manage transitions from hospital to home, or from nursing home to home, so fewer of our members are caught in that “revolving door” of diminished health and increased costs.

How Humana at Home transitions work

The Humana at Home program was designed to support health plan members during this vulnerable time. It provides a special kind of managed care for 30 days after a patient is discharged from a hospital or other facility where he or she has needed skilled nursing care. The Transitions Program’s services include:

  • Seeing the patient in the hospital before discharge
  • Visiting the patient at home within 48 hours of discharge
  • Coordinating a visit with the primary care physician within a week of discharge
  • Follow-up home visits
  • Delivery of meals and other needed items
  • Ongoing follow-up with the patient, health plan and primary care physician

At the end of the 30 days, the member and case manager are given a plan outlining the care that’s recommended to help avert unnecessary hospitalizations.

One recent internal study found that the Transitions Program reduced hospital readmissions by 35%.

Helping people with chronic conditions

Humana at Home is not just for those undergoing care transitions. It also helps people keep their diabetes, congestive heart failure, and other common chronic conditions under control and cuts down on the need for emergency care.

Through health assessments and predictive modeling, Humana finds people who could benefit from Humana at Home special care programs. Then multi-disciplinary teams evaluate the needs of individual patients, create care plans, and connect them to the resources and services they need.

In the Humana at Home special care program, the teams include care managers who stay in touch by phone; nurses and social workers who visit in person; and community health educators who figure out how to connect members with the particular community and social services they need. Services could include transporting patients to and from doctor appointments; teaching members to use home monitoring devices; seeing that they have the prescriptions and food they need; and modifying the home environment to minimize the risk of falls.

Results: The Humana at Home program is improving health and lowering costs. Our data found:

  • After six months, hospital admissions for participants drop 30–40% compared to admissions prior to management.
  • Program participants with diabetes mellitus, congestive heart failure or chronic obstructive pulmonary disease have on average a 30–40% decrease in admissions and a 20–30% drop in costs per member per month.
  • On average, the reduction in claims for participants is $330 per member per month.

The Humana at Home program is also improving quality of life. In a 2010 self-reported survey, Humana members who had had difficulties with activities of daily living (washing dishes and bathing, for example) in the previous six-month period said the program helped them in many ways, including:

  • 16% who had previously reported their health as poor to fair reported it good to excellent.
  • 14% who had reported their pain level as interfering with their daily lives reported it under control.
  • 15% who had reported falling in the previous six months reported no fall in the next six months.