Transition Care Program Coordinates Home-Based Care Following Hospitalizations

A transitional care program aimed at providing newly discharged patients with home-based care has been launched for Aetna Medicare Advantage members in Texas, according to Univita.

The program, a collaboration between Aetna and Univita Health, will help Aetna Medicare Advantage members transition from a hospital or skilled nursing facility (SNF) to their home, helping to prevent them from returning to the hospital.

“Aetna is focused on offering programs and services that help lead to better health outcomes through collaborative care coordination,” said Dr. Randall Krakauer, Aetna’s national Medicare medical director. “We already offer our Medicare Advantage members a number of care management programs to help improve the quality of care and reduce healthcare costs. The new transitional care program will help Medicare Advantage members who are treated in a hospital receive coordinated home-based care as they complete their recovery.”

Upon admission to a participating hospital, one of Univita’s specially trained nurses will reach out to the member and their caregiver. The nurse will engage the member about their condition and discharge plan in order to determine the type of support the individual will need when they go home. If the member is admitted to a SNF prior to returning home, the nurse will also visit the member while they are in the SNF.

Once home, the Univita nurse can help the member in a number of different ways, including:

  • Assessing the member’s living conditions,
  • Educating the member and caregiver on their discharge plan,
  • Describing how to take their medications properly,
  • Explaining the signs and symptoms that may warrant a call to the doctor, as well as the importance of having follow-up physician visits.

The Univita nurse will also coordinate with an Aetna nurse case manager who will be assigned to each member.

Similar programs administered by Aetna and Univita use evidence-based approaches and have been shown to reduce avoidable hospital readmissions significantly.

Source: Univita Health, January 29, 2013

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