CenterWell Home Health’s Focus On Hospital Discharges Is Paying Dividends

The transitional period between a hospital admission and the start of care for home health patients is an often overlooked aspect of a care journey.

For providers like Humana Inc. (NYSE: HUM), that time period has become a key focus in lowering costs and improving outcomes.

“The start of care is critically important for us,” Chase Dailey, a principal for Humana’s home solutions team, said during a Bright Spots in Healthcare webinar Thursday. “When you’re going through a medical event, whether planned or otherwise, those days after you leave the hospital aren’t where care stops. It’s where recovery starts.”


Based in Louisville, Kentucky, Humana is one of the largest insurers in the country. Its health care delivery arm, CenterWell, delivers home health and primary care.

Humana and CenterWell have been able to take advantage of the growing popularity of Medicare Advantage (MA) in home health care.

“We look at the data and we see that the highest likelihood of those patients ending up either back in an emergency room or an inpatient setting is going to happen in the days following that hospital admission,” Dailey said. “For us, that’s why it’s so critical in that transitional time period — when we think about the role that home health plays — that we get our clinicians engaged with those members as soon as possible. That’s true for all the delivery models we offer, including primary care and home health.”


Assessing a patient’s needs

In Humana’s view, clinicians and caregivers have to be more involved than ever in assessing a patient’s progress and diagnoses.

“Home health, for us, is anchored around those nurses and therapists,” Dailey said. “They’re coming in for a very specific skill set to help those patients with their specific needs in the home. But there’s a lot more that we can learn about while we’re in the home and there’s a lot more needs that we can provide for those patients while we’re there.”

Charting changes in behavior, assisting with activities of daily living and helping patients stay on top of medications can go a long way in improving outcomes.

All of Humana’s 9,000 in-home clinicians are trained to – and expected to – have a holistic approach to the care they provide in the home. No task is more important, however, than medication reconciliation, simply because of its correlation with hospital readmissions.

“A key component for that timely start of care and effective start to care for any patient coming onto home health is to complete that med reconciliation process,” Dailey said. “One of those most important drivers causing a readmission afterward is just the process of medications.”

CenterWell Home Health leverages virtual visits focused on medication reconciliation at the start of visits in certain markets.

So far, the results have paid off. In the early stages of the med-rec pilot with CenterWell’s pharmacy arm, pharmacists are finding medication complications about 92% of the time.

“That gives us a really unique opportunity to bring in a licensed, certified pharmacist to help that clinician and everybody wins,” Dailey said. “We get a more comprehensive review, which is going to help reduce that likelihood of having an adverse event. It’s going to support that home health clinician in helping them do that med reconciliation extremely effectively. And it’s going to give that patient the best outcome.”

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