Avoiding readmissions in the Medicare Advantage population is a significant challenge, which Harvard Pilgrim seeks to address through post-discharge follow-up with members.
Medicare’s average national hospital readmissions rate (readmission within 30 days of discharge) is approximately 19%, with almost 4% of Medicare beneficiaries having two or more readmissions within 30 days. According to data from the Center for Health Information and Analysis, the estimated annual cost of this problem for Medicare is $26 billion — $17 billion of which is considered avoidable. It is estimated that three quarters of readmissions could likely be avoided with a well-coordinated discharge plan and proper follow-up.
Post-hospitalization discharge follow-up
At Harvard Pilgrim, a nurse care manager calls a StrideSM (HMO) Medicare Advantage member after he/she is discharged from an inpatient facility to ensure that the member has a safe and appropriate transition plan in place. The nurse case manager assesses the member to identify and address any gaps in care, and focuses on medication reconciliation and medication adherence. This call may include member education, coordination of care with families and providers, and referral to a Harvard Pilgrim Disease Management program. The nurse case manager’s assessment confirms whether the patient:
- Has received discharge instructions from the hospital or facility
- Understands the discharge instructions, including any required actions or special instructions
- Has adequate caregiver support
- Understands how to appropriately use any prescribed medications and has an opportunity to discuss any potential barriers to taking prescribed medications as needed
- Has scheduled a post-discharge PCP visit (recommended within 7 days of discharge)
- Needs assistance in scheduling ancillary services (for example, help with setting up home health visits or DME delivery)
- Would benefit from enrollment in one of our disease management, complex or care management programs
Our case and disease management staff is available to you, whenever needed. If you believe a patient is at risk for a preventable readmission and may require further assistance, or if you would like to enroll your patient in our disease or care management program, please call Harvard Pilgrim’s Case Management Department at 866-750-2068.