Reduce ED And Readmission Costs For High-Risk Patients With Our "Eyes And Ears In The Home" Visit

WHO? Health plans and medical providers caring for high risk patients recently discharged or with multiple chronic conditions

WHAT? Medication, psychosocial, functional needs and safety assessments performed by highly skilled health coaches competent in cultural and linguistic diversity, adept at patient engagement and knowledgeable of community resources

WHERE? In the home, at ground zero of optimal health outcomes

WHY? Create an individualized service plan in concert with case managers, and review and revise periodically – all to keep patients out of the hospital, maximize your HEDIS quality measures and protect Medicare Advantage Star quality ratings

• Review all meds being taken, gauge patient understanding of directions for use and side effects
• Record signs and symptoms of adverse effects
• Interview for information on diagnoses, allergies, prescription affordability
• Send identified risks to a pharmacist for review and recommendation
• Pharmacist contacts provider or patient to resolve issues

• Evaluate functional capacity (Activities of Daily Living/Instrumental Activities of Daily Living)
• Record signs and symptoms of adverse effects
• Flag potential fall risks from medications, trip hazards or poor lighting
• Screen for depression (Patient Health Questionnaire 9) and cognitive impairment (Mini Mental Status Exam)
• Assess home safety, cleanliness and maintenance
• Define barriers to compliance with service plan
• Look for evidence of other issues – abuse indicators, alcohol bottles, odors, inadequate or moldy food

• Identify service and support needs of patient and caregivers
• Flag potential fall risks from medications, trip hazards or poor lighting
• Implement follow-up plan in collaboration with patient, family and case manager