Improving care transitions

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%.