A middle-aged male member has multiple chronic conditions and has had several admissions to the hospital and subsequent rehabilitation facilities. Following another stay in the hospital in September 2016, the member was discharged to the home of his brother, his caregiver. The health plan care
The health plan care coordinator arranged for skilled home services and supplies to be in place prior to discharge. In addition to home care services, a walker was ordered. Although personal care services had been previously authorized, another assessment was completed to determine eligibility for home care services due to deterioration of his health status and the continuing desire to live in the community.
Effective October 1, 2016, services were approved for a Personal Emergency Response System, bathroom grab bars and Ensure nutritional supplement. The family is able and willing to provide transportation to medical appointments and community events. The member’s brothers have received instructions and training on his health care needs through the primary care physician, the care coordinator, and skilled home care providers.
Thanks to the home supports, the member continues to live successfully in the community and has not had a hospital visit since early September 2016.