Humana Member Story

Community Well Member Success Story

History - G.S. lives alone. When initially contacted for engagement G.S. declined participation in care management stating that he was already connected with a provider and “didn’t need the extra help”. During our AAP HEDIS Campaign, MD at Home was able to schedule a visit with G.S. the last week of November to complete an Annual Wellness visit. MD At Home then provided their detailed assessment to the assigned care coordinator (Brandon).

Barrier - G.S. had previously declined care management so the care coordinator had little to no information related to G.S.’s needs or chronic conditions.

Interventions - Brandon, G.S.’s care coordinator, received and reviewed the assessment from the MD At Home Wellness Visit. Brandon then took this opportunity to reach out to G.S. to re-engage him in active care management. Brandon was able to reach G.S. and used the information that MD at Home provided to help guide his conversation. Brandon was able to complete the Health Risk Assessment and developed care goals focusing on G.S.’s hypertension and community resource needs. He engaged the team’s social worker for community resources to assist with food and utilities. He also was able to order the member a blood pressure monitor. Brandon provided G.S. with transportation information, Over the Counter catalog information, Advance Directives form/information, and a dental provider list. Brandon discussed changing his PCP to MD at Home as G.S. reported that he doesn’t have a car and needs to take take 3 different buses to get to his current provider. GS thought this was a good idea and Brandon spoke with customer service to make this change.

A few days later while the social worker (Anne) was speaking with G.S., he mentioned to that he had some concerning symptoms the night before that involved hiccups, sweating, dizziness, and weakness and had some questions. Anne was immediately able to connect G.S. to Brandon, his care coordinator. G.S. mentioned that he had contacted MD at Home to report the symptoms and they were going to have a clinician come visit him tomorrow. Brandon reviewed with G.S. our 24 hour nurse line and encouraged the member to call 911 before his MD visit if he had any of the symptoms return that he had the previous night (hiccups, sweating, dizziness and weakness).

MD at Home notified us a few days later that the member had been admitted to the hospital with a history of 2 syncopal episodes which led to a subdural hemorrhage with incidental findings of RSV and COVID. They also provided the care coordinator with the Emergency department information. When we were notified that G.S. was discharged from the hospital, our post discharge nurse outreached him and was able to complete our post discharge assessment, notify MD at Home of the discharge, and confirmed that the G.S. had an appointment scheduled for MD at Home to see the member at home.

Outcome - MD at Home and Brandon have been in close contact regarding G.S. They have been coordinating follow ups with specialists, ensuring that he has transportation to the specialist and CT scan. Brandon has worked with G.S. to locate a neurovascular neurologist that was in network. Brandon was also able to set up home delivery of G.S.’s prescriptions to take the burden off of G.S. having to pick them up. G.S. spoke with Anne the social worker recently and stated that he has been feeling better every day since he has gotten out of the hospital. He knows that he needs to watch what he eats, avoiding salty foods and additional salt. He recognizes that his BP goes up when he has more salt in his diet so he has been eating things with less salt and also trying to drink more water. He said he has already seen the benefit of this small change. G.S. also said that he has the food he needed and was working with his landlord to complete needed repairs for his gas. Brandon and MD at Home remain in close contact regarding G.S. as he continues in these early days of follow up with his specialists, his new PCP (MD at Home), and his care coordinator. With the collaborated efforts of G.S. new PCP and our Care Coordinator, G.S. remains in active care management.