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Identifying Functional Decline in High-Utilizing Medicare Advantage Patients

Fallon Community Health Plan's Home Run program provides care for high-utilizing Medicare Advantage patients at home, with the goal of reducing preventable hospital SNF admissions, readmissions and ER visits, according to Pat Zinkus, FCHP director of case management, and Susan Legacy, FCHP senior manager of case management.

We have found that the primary care provider, specialist and Visiting Nurse Association referrals have been the best referrals. These are people who know the patients. They are seeing the patients in a home setting or office most of the time. However, there is a relationship, and they have a good sense of which patients would be appropriate.

We developed criteria or guidelines to try. We did not adhere to them strictly, but they gave us a sense of the patients we were looking for. Targeted diagnoses were cardiovascular or pulmonary disease, cancer, pneumonia, stroke and staphs post-vascular surgery. In addition, when we were reviewing our members and trying to fine-tune the process, we asked ourselves, ‘We have all these diagnoses. Why are some patients more applicable to this program than others?’ The geriatrician and the nursing staff came to the same conclusion: the most appropriate patients had a functional decline and chronic illness.

The functional pieces that we saw most often were related to the fact that they either had a fall or some event that restricted their freedom of getting to the doctors, going to church or visiting people. What resulted from these events was a depression. We have seen an increase in the amount of depression that correlates with the functional decline in this population. We have also seen that once this functional decline occurs, regardless of the cause, they have more trouble adhering to their plan of care. Their support systems started to dry up because they weren’t out in the community.

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Source: Guide to Reducing Medicare Readmissions, Vol. II, June 2011


Guide to Reducing Medicare Readmissions, Vol. II

The Guide to Reducing Medicare Readmissions, Vol. II examines winning strategies to reduce preventable admissions, rehospitalizations and ER visits by high-utilizing Medicare beneficiaries. In particular, this guide details interventions launched at critical patient handoffs, a program to identify functional decline in the elderly, one of the hallmarks of high utilization, and an effort to improve medication adherence through community pharmacists.

Guide to Reducing Medicare Readmissions, Vol. II is available from the Healthcare Intelligence Network for $279 by visiting our Online Bookstore or by calling toll-free (888) 446-3530.



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