For senior citizens, there's no place like home

Program keeps seniors at home, cuts admissions

RNs, social workers coordinate the care

UCare's program aimed at helping low-income seniors to live safely on their own at home has reduced nursing home readmissions and lengths of stay in nursing homes.

When the program started in 2005, about a third of participants were in some type of nursing facility. Now the figure has dropped to 20%, according to Jeri Peters, RN, BSN, UCare's chief nursing officer.

The Minneapolis-based health insurance plan assigns care coordinators to dual eligible seniors they serve through the Minnesota Department of Human Services' Minnesota Senior Health Options (MSHO) program. They must be 65 or older, receive Medicare Parts A and B, be eligible for Medicaid benefits, and live in the 57-county geographical area served by UCare.

Members in the program who qualify for a skilled nursing level of care often are able to receive home and community-based services that allow them to stay at home under a waiver program administered by the state, Peters says.

"Seniors tend to do better psychologically if they continue to be in familiar surroundings where they feel safe, and are more comfortable. This program is a cost-effective way to provide the services seniors need to maintain their independence and live safely at home," Peters says.

The care coordinators are nurses and social workers who work closely with seniors in the program to set goals for remaining independent, Peters says. Seniors in the program typically have chronic health conditions, such as diabetes and heart failure, mobility problems and safety issues as well as psycho-social challenges, she adds.

When seniors enroll in the program, the UCare customer services department sends them a packet of information and calls to welcome them to the program and schedule an in-home visit by a care coordinator. During the initial home visits, the care coordinators complete a comprehensive assessment with the member, and family members whenever possible. They work with the member and family to develop a care plan based on the member's health and social needs.

"We arrange a whole array of services to help support independent living. These range from setting up home health care, personal care attendants and durable medical equipment, to getting their lawns mowed and meals delivered," Peters says.

After the initial meeting, the care coordinators check in regularly with members by telephone or in person, depending on the members' needs. Initially, they may visit as often as once a month, then gradually reduce contact to once every six months when members become more stable and are able to manage their day-to-day needs with the assistance of their families and services that are in place. "We want them to be independent and able to self-manage," she says.

When needed, the care coordinators can arrange for transportation to medical appointments and services as part of the members' UCare benefits. If members are withdrawn or without social contacts, the care coordinators can arrange adult day care or other community services. In most cases, bearing in mind that people are sensitive about receiving multiple phone calls for the same thing, the care coordinators leave appointment reminder calls to physician offices.

The care coordinators forward the care plan to the members' primary care providers and seek their input and feedback. Sometimes they accompany members to physician appointments if they have difficulty understanding or want someone there to support them.

The care coordinators participate in interdisciplinary meetings that are attended by physicians, RNs, social workers, and the behavioral health staff to present complex cases and receive guidance. They have access to the health plan's medical directors and pharmacists when needed.

Care coordinators receive a daily report on members who have been admitted to the hospital or a skilled nursing facility. They contact the hospital discharge planner or nursing home staff and provide information on the member, then assist in the discharge plan. They talk to the member on the telephone during the stay whenever possible and follow up within 48 hours of discharge. During the post-discharge calls, the care coordinators go over the treatment plan, the medication regimen, and make sure they have filled their prescriptions and have follow-up physician appointments. They follow members who have had a hospital or nursing facility stay closely for the first 30 days after discharge.

Some participants who are Hmong or Somali also need interpreters to help them understand western medicine. "We make a concerted effort to recruit qualified Hmong and Somali individuals to work in the care coordination department. They go with the care coordinators to help with language barriers and cultural barriers and to help the care coordinators understand traditions and rituals that are important to that specific ethnic population," she says.

When needed, care coordinators can use an interpreter for their telephone calls.

The care coordinators are experienced nurses and social workers and go through an 8-to-12-week orientation program that includes classroom instruction and job shadowing. A supervisor accompanies new care coordinators on several initial visits to assess their competency.

In geographic areas where UCare does not have care coordinators available, the health plan contracts with local healthcare systems, clinics, county public health and social service departments, and community agencies to provide care coordination. "Our philosophy is that care coordination is best done in the local community where case managers are familiar with the providers and services in that area," Peters says.