As a participant in the Centers for Medicare and Medicaid (CMS) Quality Improvement Project (QIP), Harvard Pilgrim operates transition of care support programs aimed at reducing preventable hospital readmissions.
CMS has identified hospital readmissions as a national problem. According to the 2012 Annual Survey of Hospitals, nearly 20 percent of Medicare patients in the United States are readmitted to hospitals within 30 days of discharge. Harvard Pilgrim believes that a well-coordinated discharge plan and proper follow-up are essential to promoting patient health and reducing rates of readmission.
Transition support from nurse case managers
All Harvard Pilgrim Medicare Advantage Stride HMO members receive a transition call from one of our nurse case managers within 48 hours of hospital discharge notification. During the call, the nurse case manager conducts a discharge assessment, which includes confirming whether the patient:
- Has received discharge instructions from the hospital or facility
- Understands the discharge instructions, including any required actions or special instructions
- Will be comfortable at home and 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 notified his or her PCP of the illness prior to any emergency room visits
- Has scheduled a post-discharge PCP visit (recommended within 7 days of discharge); if not, the nurse will schedule an appointment for the patient
- Needs assistance in scheduling ancillary services (for example, help with setting up home health visits or having DME supplies delivered)
Instrumental in the assessment process is a confidence scale, in which patients are asked how confident they are in their ability to take care of themselves at home with the support they have in place at this time, on a scale from one (not at all confident) to ten (extremely confident). Any rating of five or below will trigger additional outreach by a nurse case manager or social worker. Harvard Pilgrim also notifies the provider when the patient or caregiver expresses doubts regarding the plan of care or other discharge matters.
Your support is crucial in helping to prevent avoidable readmissions. We appreciate your efforts to promptly inform us when members are discharged. 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, please call Harvard Pilgrim’s case management department at 888-211-9913.