Medicare Transitions in Care Strategy: Sanford Post-Discharge Home Visit Pilot
Goal: Implement a Post-Discharge Home Visit pilot project for the SecureBlue (MSHO) population to improve transitions of care and positively impact multiple Star Rating measures, including specifically hospital readmissions
Details of the Post Discharge Home Visit Pilot: This is a six month pilot in which home health care nurses will provide a home visit to community-dwelling SecureBlue members in the first 48-72 hours (ideally) following discharge from an inpatient stay. During the visit, the nurse will complete a comprehensive assessment, including a home safety assessment and medication review, provide education, determine the need for additional home health services and facilitate follow-up appointments. This pilot will leverage the convenience of home visits to evaluate a member’s post-discharge environment, proactively address potential concerns and mitigate the risk of readmission.
Pilot Provider/Regions: Blue Plus is contracting with Sanford for this pilot. Sanford home health care nurses will provide post-discharge home visit(s) to community-dwelling SecureBlue members who are attributed to Sanford.
Counties Impacted: SecureBlue members attributed to Sanford reside in the following counties: Becker, Cass, Clay, Cottonwood, Jackson, Kittson, Lac Qui Parle, Lake of the Woods, Lincoln, Lyon, Mahnomen, Marshall, Murray, Nicollet, Nobles, Norman, Otter Tail, Pennington, Polk, Red Lake, Redwood, Rock, Roseau, Stearns, Todd, Wadena, Wilkin, Yellow Medicine.
Pilot Launch Date: February 27, 2017
Is this duplicative to the post-discharge home visit by a pharmacist? The pharmacist and home health visits are complementary. The pharmacist will complete one home visit that focuses on a comprehensive medication reconciliation whereas the home health nurse will do a broader assessment that includes a brief medication review. Blue Plus is working with Sanford and the pharmacists on how best to coordinate and work together. For example, the home health nurse may see the member first and can help prepare the member for the pharmacist visit (e.g., identify questions to ask the pharmacist).
What are we asking you to do? Blue Plus wants to make sure Care Coordinators (CCs)in the targeted areas are informed about thispilot with Sanford. You are an important resource for members and play a key role supporting members’ needs throughout transitions and across the continuum of care. We ask that you:
- Coordinate and collaborate with Sanford Home Care personnel, where appropriate:
- Sanford will reach out to the relevant SecureBlue CC Delegate or individual CC by phone or email prior to scheduling a home visit with a member. At that time, Sanford will inquire whether the member already has home care in place and if there are any issues the nurse should be aware of before scheduling a visit. If the member already has home care in place, Sanford will not do a post-discharge home visit. Instead, please evaluate whether the member would benefit from a post-discharge home visit from his or her current home care agency.
- IfSanford conducts additional home visits during the 30 days post-discharge, and recommends additional Medicaid home care services, the home care nurse will reach out to the SecureBlue CCto request authorization. They may also reach out if additional issues arise where the CC may help (e.g., need for additional supports and services).
- Educate the member, where appropriate, about the benefit of the post-discharge visits available to them (i.e., home health and pharmacist visits).
Questions? Please reach out to Lisa Benrud at 651-662-1072 .
Blue Cross® and Blue Shield® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association