By Ellen Nason
Navigating our nation’s complex, costly and fragmented healthcare system can be a daunting task for even a healthy person dealing with a temporary minor illness. Imagine how dizzying and hopeless it can seem for those who live with chronic conditions such as diabetes, congestive heart failure or coronary artery disease. How do they cope with multiple doctor visits and medications, transportation issues, potential job loss and, in some cases, living alone?
The national Humana Cares/SeniorBridge Chronic Care Program is helping ease the burden for more than 225,000 chronically ill Humana members by providing personalized, integrated care management services that reduce hospitalizations, readmissions and costs while improving their quality of life.
“Humana Cares/Senior Bridge is such an important part of Humana and our integrated care delivery model,” Humana President and CEO Bruce Broussard told members of the Humana Chronic Care Program team during a recent visit to the national care center in St. Petersburg, FL. “It’s the pride of the company.”
“It’s a perfect illustration of how an integrated approach to lifelong well-being can improve outcomes, lower costs and create a better, simplified healthcare experience,” Broussard added.
Making connections, making a difference
Lynece Hand, a registered nurse, has seen firsthand the positive, empowering effects the Chronic Care Program can have on those with chronic conditions.
“We help educate our members about managing chronic disease; encourage and remind them to get preventive screenings; set goals for improving health; and, with frequent contact, learn what their greatest health concerns are, what motivates them,” Hand said. “We can then guide them to develop and reach goals that bring a better quality – and quantity – of life.”
While talking to a member in Texas, she learned that he was struggling with chronic insomnia and had been unable to work for eight years. Hand reviewed the medications he was taking and discovered that insomnia was a possible side effect of one of them. She discussed the issue with the member’s doctor, who instructed his patient to take the medication at a different time of day. The member no longer has insomnia, has returned to work as a substitute teacher and is working on his teaching certificate.
The Humana Chronic Care Program goes beyond medical considerations, and looks at the whole person and areas of concern that could adversely affect physical or mental health, whether it is financial, social or legal issues. Hand is passionate about helping improve health and reduce hospitalizations, but she also treasures the relationships she develops through her work.
“While talking about a medical issue, such as diabetes, members may identify something else that is going on – whether it is a family issue or a recent death – that may be affecting their health,” said Hand. In addition to helping the member in Texas with his own health, Hand resolved a concern he had with his son’s health. The previously healthy young man who enjoyed a full life suddenly suffered extreme fatigue, weight loss, several hospitalizations and could no longer work. Hand knew the family enjoyed hunting, and with a little investigation, was able to pinpoint the source of the son’s problem. He had contracted an infectious disease through contact with an animal during a hunting trip. A simple treatment with antibiotics solved the issue, and the son is once again healthy and enjoying life to the fullest.
How it works: Coordinate, connect, simplify
Members who are eligible for the Humana Chronic Care Program are proactively chosen using a predictive model to identify those who have chronic conditions that are the most difficult to manage and may require the most assistance. Once a member is enrolled in the program, an assessment is made to identify the types of services that may be needed: health education and coaching, regular telephonic contact or home visits, medication education, physician care coordination, end-of-life planning, depression screening, post-hospital discharge support, in-home safety assessments, remote home health monitoring, meal and transportation assistance or caregiver training and support.
To meet these needs, the multi-disciplinary Humana Chronic Care Program team, which is one phone call away for members, includes social workers, community health educators, registered nurses and other healthcare workers.
Debra Kleesattel, Director of Operations for Humana Cares/SeniorBridge, has been with Humana Cares, headquartered in St. Petersburg, FL., for several years and has witnessed enormous growth and an expanding national footprint and capabilities with the 2012 acquisition of SeniorBridge.
The Humana Cares/SeniorBridge program helps Medicare Advantage members age at home, the chronically ill stay out of hospitals and all of them navigate a disjointed and confusing system, said Kleesattel, who has a PhD in gerontology.
“We bring all the parts and pieces that don’t seem to fit and put them all together for the individual,” she said. “We look at all areas of life. A caregiver may have diabetes and neglect his own needs because of the demands of being a caregiver to his wife who has Alzheimer’s. We connect the caregiver with a local area agency that can provide a break, change his perspective and improve his own health. Or maybe it’s a financial issue, such as someone who needs a wheelchair ramp but can’t afford it. We connect them to the resources they need, which enables them to focus on better health decisions that keep them out of the hospital.”
“We make sure they know that we walk beside them and are here when they need us,” Kleesattel said.
By the numbers
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- To date, Humana Cares/SeniorBridge members have experienced a 26 percent decline in inpatient admissions; and 18 percent drop in hospital readmissions; and 10 percent reduction in emergency room visits.
- Personalized, telephonic care management, health coaching, health education and health support provided by registered nurses and other health professionals across all 50 states.
- Community-based, in-home assessments and care management by nurses, social workers or community health educators in 32 states and Washington, D.C.