By Roy A. Beveridge, MD
If you know a senior who’s recently been discharged from the hospital, you know she’s doing everything she can to stay in her home. Returning to the hospital is a big step backward.
Avoiding a hospital readmission is a serious challenge for many seniors. According to the Department of Health and Human Services, “nearly every fifth hospitalization among Medicare fee-for-service (FFS) beneficiaries who were discharged from the hospital alive resulted in a subsequent readmission within 30 days.”
At Humana, we’ve used the power of the value-based care reimbursement model to support physician practices in keeping their patients with Medicare Advantage (MA) in their homes and out of the hospital. In 2016, these MA members experienced, on average, “6% fewer hospital inpatient admissions and 7% fewer emergency department visits than members in standard Medicare Advantage settings.” These results can also lead to a considerable reduction in morbidity and risk the patient.
Despite the progress, our members, such as “Carol,” can still wind up being readmitted to the hospital.
It starts with a discharge
Carol is a 72-year-old widow who lives alone. She is living with diabetes, heart failure, and COPD. The last time Carol was discharged from the hospital, she had no clear follow-up plan. Days passed before her home-care company helped arrange for her to see a doctor, which left her unsure if she was taking the right medicine or if symptoms that arose were expected or warranted a return to the hospital.
There was no hand-off. Her care team didn’t receive important data — like her medical history, list of medications, or personal circumstances that could hinder her health.
This type of experience is what lands people like Carol back in the hospital. We can do better. And it’s why Humana decided to invest in Kindred at Home.
Serving members through care
Long before Humana announced its Kindred At Home agreement, Humana At Home has been providing care coordination services for hundreds of thousands of Humana MA members like Carol who are living with chronic conditions. These services are provided in the home for up to 30 days after a patient is discharged.
The purpose of Humana At Home is to help Carol and others live independently, and safely, in their homes. The approach has worked, as evidenced by a 44% decrease in hospitalizations for those at highest risk for frequent admissions and a 32% decrease in hospital readmissions resulting from our 30-day transitions care management service.
However, many Humana At Home professionals face care restrictions. They do not have home health licenses, which means they can’t draw blood or even take blood pressure. They can see if the bathroom is safe or if the patient needs a ramp at their house for ease of mobility, but can’t touch the patient or perform a physical examination.
Enter Kindred at Home
Humana at Home and Kindred at Home complement one another in mission and purpose. By working together patient care can be optimized to improve in-home health care to help people like Carol.
For Carol, who has diabetes and is at risk for foot ulcers that, left untreated, can lead to amputation, the Kindred at Home nurse can examine her foot and apply wound care if needed. The nurse can also check Carol’s blood pressure and her weight, alerting the physician of a change — as any change in Carol, who has heart disease, could lead to readmission.
Since Carol lives with COPD, the nurse can use predictive analytics to alert the physician to a potential exacerbation or use remote monitoring to make sure her breathing is stable. Moreover, through telemedicine, the Kindred at Home nurse can instantly connect Carol from her home to her doctor — including a specialist or pharmacist, ensuring Carol gets optimal care and assures she is doing everything she can to stay in her home.
It’s the difference between Carol feeling alone on an island and feeling secure in her home. It’s the difference between Carol feeling anxious in her ability to care for herself and feeling supported by a care team that can get her close to her physician whenever she needs it.
Humana and Kindred are a powerful duo and have the ability to transform home health care. Together, through post-acute visits, care coordination, clinical services, technology, and data and analytics, we’re able to extend the physician and their practice so Carol and others are able to stay where they want to be — at home.
Dr. Roy Beveridge joined Humana in 2013 as Chief Medical Officer. He is responsible for developing and implementing Humana’s clinical strategy, with an emphasis on advancing the company’s integrated care delivery model.
Dr. Beveridge is known for creating collaborative environments among physician communities and providing thought leadership around population health. He is a member of the Management Team, which sets the firm’s strategic direction, and reports to President and Chief Executive Officer Bruce Broussard.
Previously, Dr. Beveridge served as Chief Medical Officer for McKesson Specialty Health. Prior to McKesson’s acquisition of US Oncology in 2010, he served as the Executive Vice President and Medical Director at US Oncology. He has published extensively in the fields of medical oncology, stem cell transplantation, quality design and population health.