By Ellen Nason
Bruce Weaver had a heart attack hundreds of miles from his North Carolina home a few years ago, but the energetic 75-year-old has fully recovered and is back on the road, spending this summer traveling with his wife, Ruth. He is thankful for everyone who worked with him on his journey to better health: family and friends, his doctors, physical therapists and Lynece Hand, his Humana At Home personal care manager.
Weaver, who is also a diabetic, was contacted by Hand, a registered nurse, soon after his heart attack. He appreciates that she has helped him set and meet goals and motivated him to exercise, but he also treasures the personal, trusting relationship they have developed.
“She is joyful,” said Weaver, who looks forward to her regular calls, even when he is out on the road. “It’s relaxing to talk to her.” Weaver, who now lives in Inverness, Florida, said that he may not always have questions about medications or other aspects of his physical health, but he knows Hand is always ready to listen to any concerns, answer questions and understand.
“Other people who have had a heart attack don’t always have that,” he said. Weaver, who has lost 40 pounds, said he’s feeling great, and his cardiologist recently told him to “keep doing what you’re doing.”
“It is fulfilling to be able to help,” said Hand, who attributes Weaver’s recovery to the fact that he is actively engaged in improving his health and dedicated to staying active and learning.
Hand believes Humana At Home, formerly called Humana Cares/SeniorBridge, is successful in part because of its holistic approach. The care managers take time to learn participants’ stories, enabling them to focus on specific areas of concern that could adversely affect their physical and mental health.
Hand said this leads to a more personalized care plan, whether it is health education and coaching, health care provider coordination, in-home visits and safety assessments or caregiver support. As the care managers become more familiar with Humana At Home participants’ needs, they also may connect them with social workers or other community resources to help with issues relating to finances, transportation or loneliness.
Humana At Home, which now serves nearly 600,000 people nationwide, focuses on those with multiple chronic conditions and those who need help transitioning after being discharged from the hospital. The goal is to keep people living safely and comfortably in their own home.
“It is a holistic approach … it’s just not purely disease management,” said Craig Drablos, Chief of Operations, Humana At Home. “We’re trying to take care of the whole person, the whole self and by doing that, we’re keeping people out of the hospital. We’re seeing that the readmission rate when we do this drops about 40 percent for these people.
“This whole program is designed around achieving lifelong well-being,” said Drablos. “I’m not sure of any other program out there right now that supports the members in the way that we’re supporting our members.”
Hand works with 205 members, but her contact is mainly telephonic. While that method works for many, some need or prefer in-home visits.
Ernestine Marshall, a retired teacher, has diabetes and multiple sclerosis. She said she is coping with her illnesses better through dietary changes, exercise, ongoing education and gaining confidence in herself. She attributes many of the changes, particularly her growing confidence, to the connection she has with John Webb, a Humana At Home field care manager, who visits her each week at her home in Tampa, Florida.
“I know I can call him if I have any problems,” said Marshall. “It makes me feel better. I even feel important sometimes. I know someone is there.” She said she looks forward to Webb’s weekly visits and knows he’ll either have answers to her questions or find the answers for her.
Marshall also participates in a Healthsense remote monitoring pilot program through Humana At Home. The sensors are placed in key areas of her home to detect movement and help monitor possible problems. “If I fall or can’t move, someone will notice,” she said. “I can stay safely in my home and be comfortable.”
Helping members enhance their health while living safely at home is the goal, said Webb, who looks at the program as a partnership with members because it requires their engagement and willingness to set and work on goals.
Webb said that Marshall is highly motivated and is reaching her goals, such as recently traveling to a family reunion in Atlanta, which was out of her normal routine.
“It’s the best system, the best program,” said Marshall. “I like it. I would not change it for anything else.”