Improving care transitions and chronic care

According to most national studies, about 15 to 20 percent of patients discharged from hospitals are readmitted within 30 days. A 2016 report by the Dartmouth Atlas Project elaborates that many readmissions “are caused by inadequate discharge planning, poor care coordination between hospital and community clinicians, and/or the lack of effective longitudinal community-based care.” 

Some readmissions can’t be helped, of course, but many can and should be prevented. In fact, according to a 2015 report from the Center for Health Information and Analysis, this is one of the biggest problems the U.S. healthcare system faces with 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 works

The Humana At Home mission is to help our most vulnerable members with medical and functional challenges remain safe and independent at home. Transitions provides care management by nurses and social workers for up to 30 days after a patient is discharged from a hospital or other facility where he or she has needed skilled nursing care. The Transitions services can help members:

  • Make an easier transition to home within 48 hours of a hospital or skilled nursing facility discharge
  • Understand their doctor’s advice
  • Learn about and find ways to afford their medicine
  • Ensure that their home is a safe place to live
  • Get meals and groceries
  • Find options to help with their finances

Helping people with chronic conditions

Humana At Home is not just for members’ transitions from the hospital to home. 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 reaches out to eligible members who may benefit from long-term, in-home care at no extra cost to them. Then, multi-disciplinary teams evaluate the needs of individual members, create care plans, and connect them to the resources and services they need.

The Humana At Home long-term, in-home service teams include care managers who stay in touch by phone; nurses and social workers who visit in person; and community health educators who find and connect members to local community and social services resources. Services generally start via an in-home visit within 48 hours of discharge and may help members …

  • Understand their doctor’s advice
  • Find resources to better afford their medicine
  • Ensure their home is a safe place to live
  • Get meals and groceries
  • Find options to help with their finances

Results: The Humana At Home service is improving health and lowering costs. Our data found that, after six months, hospital admissions for participants drop 44 percent compared to admissions prior to management.