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TRANSCRIPT
Personal Home Care Services for Medicare AdvantageMembers
10/12/2019
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Personal Home Care Services for Medicare AdvantageRuthi Farrago, Director of Operations
SeniorBridgeSession 204
Evolution of Medicare & Supplemental Benefits
1997 Medicare Part C
(Adds Transport, Vision, Dental)
2003Social HMODemo Ends
2003 Medicare Part D
(Drug coverage)
2019Supplemental
Medical
2020Supp. Non‐Medical
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Special Supplemental Benefits for Chronically Ill (SSBCI)
• Meals
• Transportation for non‐medical needs
• Pest control, air quality, and other home environment help
• Social needs benefits
• Complementary Therapies
• Services supporting self‐direction
• General supports for living
Shifting from “What’s the matter” to “What matters”
Lessons Learned
Using human‐centered design to find out what matters
Lack of experience makes bid filing
difficult
Implementation requires new
processes, rules, and partnerships
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What’s next?
• Chronic illness vs. functional status
• Understanding Value
• Changes in Community Based Organizations
Activity limitations and Chronic Illnesses
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Click to edit Master title style• Relative Risk of being a High Cost Patient
Relative Risk of being among the top 5% Most Costly Patients Increases as Patients with Chronic Conditions Develop Function/Activity Limitations
Source: LewinGroup analysis of 2006 Medical Expenditures Panel Survey, 2010
Click to edit Master title style• People with Chronic Illness and Activity Limitations have More Inpatient stays and Higher Care Costs
Source: Robert Wood Johnson Foundation, Chronic Care: Making the Case for Ongoing Care,Medical Expenditure Panel Survey, 2006
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Click to edit Master title style• Disability Drives Health Care Costs in the Medicare Population
Source: Long Term Care: An Essential Element of Health Care Reform, The Scan Foundation 2008.
Click to edit Master title style• Hypothetical: Impact of Caregiving on Hospitalization Rate in Medicare
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Development of Personal Home Care Benefit
Respite Care Benefit Journey
3. Ease of access to benefit
1. Caregiver needs respite
As part of their plan, eligible members call the phone number on the back of their card to receive an in‐home evaluation by a registered nurse.
2. Caregiver and Member reach out for support 4. Identify any issues related to
social determinants of healthBeing in the home allows greater awareness of external challenges the member faces and how to help address them thru other programs or services.
The family caregiver is having trouble keeping up with the roles’ demands and needs a break to avoid burnout.
Scheduling adjustments, plan of care, etc. all managed by local branch to provide flexibility and build rapport between Humana and member/caregiver.
6. Inclusive of the family caregiver
Family caregiver accounted for each step of the process, keeping them informed and measuring the impact to them as well as satisfaction .
Consumer pain point
Opportunity
Key
5. Face‐to‐face interactions build trust
The benefit can allow the caregiver to leave the care recipient in safe environment, avoiding admission to a facility or out of pocket expenses that are not budgeted.
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Click to edit Master title styleBuilding a new supplemental benefit
• Built IT infrastructure• Met CMS audit requirements• Scalability• Cross organizational trainings• Actuarial analysis of cost
staffing and anticipated member utilization for a competitive per member, per month rate
• Program specific assessment for benefit determination
• National footprint
Program Overview
Member receives supervisionbecause it is no longer safe for member to be left alone.
Member resides at home
Must not be in a nursing facility or health facility that provides 24/7 care.
Member receives short term personal home care services and support with activities of daily living.
Member can be assured of receiving quality care by a licensed home care agency.
Begins January 1, 2019
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Click to edit Master title style
Home Health AidePaid care worker providing the Personal Care
Services benefit
BathingIncludes helping with washing, shampooing, getting in or out of the tub or shower brushing teeth, and other aspects of personal grooming.
DressingHelping member to put on or take off clothing and footwear.
TransferringAssisting member get to and from a bed or chair.
Walking/MobilityIncludes helping member move from one stationary point to another by removing obstacles, opening doors, and assisting with canes, wheelchairs or other assistive devices.
Short term personal home care for members in their home
ToiletingAssisting member get on or off the toilet, commode or bedpan, and to clean self, or the individual is incontinent.
Medication RemindersLimited to the following:
• Obtaining the medication container from the storage area for the patient or client.
• Reminding the patient or client that it is time to take the medication as prescribed.
• Observing the patient or client self‐administering the medication .
Care Available• Up to 42 hours per calendar year
• 3 hours per day (minimum)
Eating and Meal PreparationAssistance with food preparation, meal reminders and assistance with feeding.
PHCS 2019 Target Markets
TX – San Antonio and Houston
FL – Miami Dade, Broward, and Palm Beach
2019 Membership projected at 132,500 for the five markets
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ConsumerImpact
Identifying Social Determinants of Health Needs
• Food Insecurity
• Social Isolation
• Financial strain related to ability to
afford medications
• Ability to access transportation for
medical appointments
Evaluate caregiver stress upon
admission and upon discharge
• Net Promotor Score
• Grievance and Appeal
Tracking
Member Satisfaction
Reduce Caregiver Stress
What we learned
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PHCS Referral Volume 2019
Through the first nine months of the service offering;• 1,224 referrals have been
received• 982 referrals (80%) in FL
• 202 (17%) of the referrals were urgent with a spike in July and August.
• September had the second highest number of referrals to date ‐ 171.
PHCS is averaging 136 referrals a month in 2019
PHCS Active Member Population
• 375 of the 588 (64%) members enrolled in the service are still active.
• Of the 213 members discharged;
64% of the enrolled members are still active in the PHCS program receiving services
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PHCS Active Member Population
• 376 of the 518 (73%) members enrolled in the service are still active.
• Of the 142 members discharged;
73% of the enrolled members are still active in the PHCS program receiving services
PHCS Enrollment Cycle Time in August
100% of the non‐urgent members were enrolled in the 14 day window.
The PHCS team was in compliance with enrollment requirements in August
100% of the urgent members were enrolled in the 72 hour (3 day) window.
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PHCS Bold Goal Summary Data
Click to edit Master title styleLessons Learned
Referral patterns
Member or family self‐identification• Caregiver stress & burnout
In‐home/Telephonic care manager• Clinician identified member at
risk and in need of personal care services
Providers• Member at‐risk for
hospitalization or ER utilization Other professionals involved in
members’ care
Members using minimum hours per week, despite having need for more hours per week, in order to maximize the number of weeks of care
Members extremely appreciative of benefit offering and expressed they would renew their benefit in 2020
Family caregivers relieved at having options to support care needs
The in‐home assessment process is effective as only 3% (11) of all members have been found to not qualify after the initial in home assessment was completed.
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“How Humana Helped My Mom…” ‐ Rosa’s Perspective
Click to edit Master title style Meet Elisa’s Team…
Jhoannel, RN PHCS NurseCompleted Elisa’s in‐home assessment
JasmineUM Coordinator
Referred Elisa to respite care program after hospitalization
Maralyn, HHASeniorBridge Caregiver
Labridgeda, PHCS SchedulerMatched Elisa with her caregiver, Maralyn
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Click to edit Master title style Elisa, 86 years old
Elisa’s life
• Lives with adult daughter, Rosa
• Likes watching TV, playing games and tending to her plants
• Used to enjoy going on trips, to concerts and the movies
• Feels more comfortable at home, then going out, due to her health
Elisa’s health conditions Rosa’s life
• Beginning stages of dementia, borderline Type 2 Diabetes, blind in right eye, carpal tunnel in both wrists
• Hospitalized for COPD exacerbation week prior to respite care
• Uses walker, new to using oxygen after hospitalization
Rosa’s life
• Sole caregiver for Elisa for 19 years
• Works 12 – 13 hours days
• Has cameras in her home to monitor Elisa while at work
• Worries about Elisa when at the gym or out with friends
Click to edit Master title styleElsa’s Barriers to Well‐Being
• Not comfortable going outside alone with walker.
Mobility
• Forgets to use walker when going to another room and creates fall risk.
Safety
• LTC paperwork and approval is lengthy process. Still pending after two months.
Difficult to navigate health system
• Unable to bathe unless daughter is home.
Functional limitations and personal care
• Daughter is constantly checking on Elisa with home monitoring video on her phone, while at work and while trying to have a her own personal life.
Stress
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Click to edit Master title styleElisa’s PHCS Experience
Assisted with
bathing
Prepared meals
Accompanied outside
Played games
Got member active
Got member active
No longer felt
lonely
Frequency: Every Wednesday and Thursday for 3 hours from 3/16/19 until 5/2/19
Click to edit Master title styleHow We Helped Elisa and Rosa…
• “Thankful for the attention given to my Mom by Maralyn.”
• “I saw a difference in the way she carried herself, her attitude and demeanor”
• “My Mom no longer felt lonely.”
• “I had 6 hours a week where I was not worried about my Mom at home.”
• “My Mom would wait for Maralyn at the door every Tuesday and Thursday.”
• “Maralyn was a great match for my Mom. We hope to have her again in 2020.”
• “Maralyn became my Mom’s best friend.”
• “They would have breakfast and lunch together and talk.”
• “Maralyn got my Mom outside in the fresh air playing games on the porch.”
• “Grateful the scheduler found a Spanish speaking caregiver for my Mom.”
• “Two months later and my Mom still talks about Maralyn.”
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Click to edit Master title styleImprovement Opportunities
Offer more than 42 hours per year. Many members are not utilizing the
benefit for fear of needing the hours near the end of the year.
“I wish more than 42 hours of care per year was offered. Seven weeks went
by so fast. Maralyn’s visits made a difference in both our lives.” ~ Rosa
Improve communication between respite care program and care
managers to better serve our members.
Improve awareness and education of respite care benefit within
Humana.
Future Expansion of Benefits
Personal Home Care Services• Respite & Chronic Care
• Increased benefit hours• At‐risk members
• Social determinants• At risk for nursing home placement
• Transitions of Care
• Catastrophic Care
SeniorBridge has a national footprint of home care agencies to support all markets inclusion with this benefit offering
