Transition care, in-home visits pay off for health plan

Transition care, in-home visits pay off for health plan

At-risk patients are targeted for interventions

In the pilot of a program that provides physician visits at home to at-risk members, Florida Blue achieved savings of almost $2,500 a month for each participating member.

"We got really good results from the program, which originally focused on homebound patients. We’ve expanded the program to include a broader group of patients who are at risk for being readmitted to the hospital. Our commitment is to make sure members are cared for in the most effective way possible and to prevent readmissions and emergency department visits," says Elizabeth Barnett, BSN, JD, senior director of care coordination for Florida Blue.

The Physician-at-Home program is an outgrowth of Florida Blue’s Physician Assessment Treatment and Consultation at Home (PATCH) program in which physicians and nurse practitioners visited at-risk homebound patients in their home until the patients were able to manage their own care effectively. Patients targeted for the program were admitted to the hospital frequently or had frequent emergency department visits.

Now, the health plan has expanded the program beyond homebound patients to those who need extra care after discharge. Florida Blue’s transition nurse case management team works with members who have been readmitted to the hospital, those who have been identified as high risk for readmission, and those whose length of stay is 10 days or longer. The transition nurse case managers coordinate care as the members transition from the inpatient setting or a subacute facility to home and provide short-term case management after discharge. They refer appropriate patients to the physician-at-home program. Other patients for the program are identified by case managers, concurrent reviewers, hospital staff, or physicians.

The transition case managers continue to work with the physicians and nurse practitioners when patients are part of the physician-in-the-home program. The physicians and nurse practitioners provide the medical care and the transition case managers provide care coordination services. The team has a social worker who helps refer members to community organizations and other resources that can meet their needs.

Typically, the physicians make the initial visit and nurse practitioners follow up, visiting the members at least once a month. The clinicians conduct medication reconciliation to make sure patients are taking their prescribed medication appropriately and are not taking medications that are duplicates or are contraindicated with their discharge medication. They may adjust medications to improve pain management, provide wound care, or consult with patients and families about palliative care. They give members and their families the phone number of a physician to call 24-7 instead of calling 911 if problems or questions occur after regular physician office hours.

The transition nurses reach out while patients are still in the hospital or subacute facility. "We want to reach them while they are inpatients and are a captive audience and more likely to engage. We tried calling after discharge, but many of them were unable or unwilling to answer the phones and our success rate at reaching them was less than 50%," she says.

The transition case managers don’t see every member personally. They make it a point to visit members with whom there have been challenges in the past while they are in the hospital. They contact the others by telephone while they are in the hospital and set up a time for a follow-up call.

When members have extensive psycho-social needs, the transition case managers call in the social work team to help connect patients with funding sources for services not covered under the plan or for assistance with co-pays. They help members apply for disability and other assistance and get involved if long-term placement is needed. The nurses set up services such as Meals on Wheels or housekeeping assistance.

The program has a member-centered case management model with one case manager as primary coordinator. "Even though social workers, diabetic nurse educators, or other clinicians may get involved, the case manager remains the central point," she says.

The transition case managers collaborate with Florida Blue’s concurrent review staff to ensure that the patient has a smooth discharge. The concurrent review staff also work with the hospital discharge planner on the discharge plan and post-discharge needs. The transition nurse works with the members to make sure they understand the plan and can follow through with what they need to do.

Under the PATCH program, physicians and nurse practitioners visit patients in their homes for an average of just over four months. The transition case managers generally work with them for about six weeks after discharge. "We want to get the members what they need after discharge. If they continue to need care coordination or have complex needs, we generally transition them to long-term case managers who can provide coordination from a catastrophic or specialty perspective," she says.