This article was contributed by the Beneficiary and Family Centered Care National Coordinating Center
November is National Family Caregivers Month—the perfect time to talk about how Medicare patients can work with their families and caregivers to take good care of themselves.
Annual wellness visits to primary care physicians are a first step. These visits can include keeping updated on chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD). While thinking about next steps about their care, some patients may talk with friends and family members who work in the medical field and know how the health care system works, such as physicians, nurses or technicians. But, what if patients don’t have a go-to person to help them figure things out?
The Centers for Medicare & Medicaid Services (CMS) offers a Healthcare Navigation program, which could be the answer for many patients. People with Medicare can call their Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) to enroll in the free program. This program has the potential of creating direction for them as they go through the health care system and are connected to care they need in different care settings such as hospitals, skilled nursing facilities (SNFs) and home health care agencies. The Healthcare Navigation program has been helpful during care transitions when patients go from one care setting to another, for example, when they leave the hospital and enter an SNF.
KEPRO and Livanta are the QIO Program’s two BFCC-QIOs that provide free Healthcare Navigation programs for people with Medicare. Below are some frequently asked questions and responses about their programs.
1. How do you help Medicare patients and families decide what to do after a hospital discharge, especially if the patient isn’t ready to go back home?
Livanta: One goal of the Healthcare Navigation program is to get patients to the point where they feel confident about transitioning home or to a lower level of care. Receiving support and information from the BFCC-QIO, patients become more confident in their understanding of how to access resources and services that are available.
Example: Livanta had a patient who was in the hospital due to a stroke. As the time came for the patient to leave the hospital, he became concerned that he had not received training on a special type of walker he was going to have at home. Livanta spoke with hospital staff to help everyone understand the patient education that needed to happen before the patient left the hospital. Then, when the patient was home, he was told that he needed to have outpatient physical therapy but was never told how to make that happen. Livanta talked him through the process of contacting his primary care physician and made sure the patient knew how to follow through.
KEPRO: When KEPRO speaks with patients who are still in the hospital, staff begins with promoting good communication between patients (and families) and provider staff. KEPRO helps patients understand what care, services and medical equipment are available to them after they leave the hospital. If patients have lost a recent discharge appeal, KEPRO staff helps them understand the options that are available to them.
2. What topics arise during transitions between settings of care?
KEPRO: One main concern is safety. Patients need to feel safe in their own homes. They also need to know about social support that is available and how to get those services.
Example: KEPRO staff helps family members see the patient’s home from his or her point of view by taking them through the scenario of the patient’s arrival home from the hospital. One example could be a patient who had a fractured hip. KEPRO staff asks questions to help the patient and family identify what, if anything, might need to change to reduce the risk of falls. They might start with installing grab bars, removing throw rugs or rearranging furniture to allow for a walker or cane. They might want to use cell phones to talk with others in the house more easily. KEPRO helps families work out the details of what they need to think about. KEPRO also provides information about resources that are available in the community, such as nutrition programs or meal delivery.
Livanta: Sometimes patients have concerns about how they will continue to get better at home. Patients ask, “Should I continue to get therapy?” If patients don’t understand their discharge plan, Livanta suggests they ask for a plan of care meeting with provider staff. Patients often do not have a good understanding of their treatment plan. Livanta teaches them how to get the help and support they need by asking questions. Health care providers are glad patients ask for meetings, so both patients and health care providers can deal with the situation with more confidence. Livanta and providers are 100 percent focused on patients and the best way to work together to get them what they need.
3. Do you speak with patients and families about medications during transitions of care? What kinds of issues do you assist with regarding medications?
Livanta: Patients and caregivers should get a copy of their discharge plan and have it explained to them. This includes a list of medications that patients started taking in the hospital and are bringing home. Sometimes patients and caregivers do not understand the discharge plan or may not be comfortable asking questions about it. Livanta walks them through each of the medications and instructions, and asks questions such as, “Do you know what that pill is?” “Do you know why you are taking it?” “Are you taking any other medications?” And, “Do you have a pill box and know how to set up your pills?” Livanta suggests that patients take the completed list with them to follow-up appointments with physician(s).
Livanta helps patients understand how to get the answers to their questions. For example, a patient might try to get a prescription filled, but the pharmacy staff tells him or her that a needed piece of information for getting the prescription filled is missing. Livanta talks with patients about how to resolve that issue. Sometimes pharmacists can call the primary care physician and move forward with refilling the prescription. Livanta speaks with patients after they go to follow-up appointments with physicians. They talk about how each appointment went and listen for any continuity of care issues (e.g., is one medication contraindicating another) and ask patients if all their questions were answered.
KEPRO: During the transition of patients from hospital (or SNF) to home, KEPRO staff speaks with them about the importance of having prescriptions called in to their preferred pharmacy. Prescriptions include ongoing medications (medications patients were taking before going into the hospital or SNF) and any new medications prescribed during their stay. Patients need to know about their medications, including their purpose and why it is important that they take them. To be sure patients understand, KEPRO asks them to repeat instructions back to the patient navigator (KEPRO staff) and may do a follow-up call to be sure medications were taken.
Example: Recently, KEPRO had a patient who didn’t want to take a medication because she thought it was contributing to her edema (swelling caused by excess fluid trapped in the body's tissues). KEPRO talked with her about her condition and the purpose of the medication and why it was given. KEPRO also encouraged her to call her doctor’s office to ask if there was a better medication for her.
The Healthcare Navigation program provides a go-to person for Medicare patients and their families to help them figure out how to move forward with their health care and get needed services. Visit the QIO Program website to read more about the Healthcare Navigation program and for contact information for your BFCC-QIO. Watch a new video on Healthcare Navigation from KEPRO.