From home sensors that monitor daily motion and sleep abnormalities, to video visits using teleconferencing, Humana is doing its best to ensure that the frail elderly can remain at home as long as possible.
When integrated with a telephonic care management program, these remote monitoring technologies have helped Humana to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges, says Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. The pilots are part of a continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.
Most Americans are living longer, and suffering fewer deaths from acute illness, Miller said in a recent Healthcare Intelligence Network webinar, Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results. But they are also developing more chronic illnesses and functional limitations, which are often the costliest to manage.
Despite their growing frailty, however, nine out of 10 Americans prefer to age at home, she continues. To help them live independently and age gracefully at home, Humana, which has over 30 years experience in the Medicare program, and over two and a half million Medicare advantage members, launched the Humana Chronic Care Program (HCCP). Targeting the members most in need, or the sickest 20 percent, which drive 75 percent of the company’s costs, the company implemented a series of nine healthcare remote monitoring pilots for individuals with congestive heart failure (CHF) and diabetes as well those with medication adherence problems. The pilots also target those with functional challenges that make activities of daily living (ADL) challenging.
“There is a clear need to look beyond disease and address functional limitations,” Miller says.
One of the pilots includes strategically placed home-based sensors that monitor ADL levels of those with functional impairment. Algorithms detect abnormalities in the patients’ activities, i.e. erratic sleeping behaviors or toileting patterns that can signal infections, which then generate alerts for recommended interventions.
Video visits include two way audio-video communications so that care managers can interact with their sickest members as an adjunct to home visits. Members are given tablets to use for face-to-face contact with their care manager, or to go over any educational materials their care managers or physician provides them.
Ranging from passive to active monitoring, all of the technologies are senior-friendly, and designed to help members manage their conditions, reduce hospitalizations and improve the patient/member experience, Miller says.
A mobile Personal Emergency Response System (PERS), for those that live alone or have limited caregiver support, has been the most popular, Miller says. Members are mailed a cellular device that can be activated manually by a button, or automatically via an accelerometer. Once turned on, the PERS device connects the member to clinically trained emergency support. Many patients have asked if they could extend their use of this particular device once the pilot was over, Miller says. She explains why:
Besides being a health issue, I think the device also speaks to the level of safety concerns that a lot of seniors who have multiple chronic conditions, and who live alone, have. They don’t want to necessarily reach out to their neighbors all the time. This provides them some peace of mind, which is the ultimate goal of the program.
Listen to an interview with Gail Miller of Humana Cares/SeniorBridge here.
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Decreased hospital readmissions leads to improved patient outcomes, which improves brand reputation, ultimately leading to increased patient volume and market share. Reducing readmissions begins with creating a seamless care transition plan for what will happen within the hospital as well as after discharge, according to a new infographic by the Studer Group.
A care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program. Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS’s recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare. 
