Readmissions can occur secondary to a variety of causes including SDoH. Readmission Prevention activity begins as soon as we are notified of a member’s hospital discharge. Our staff conducts telephonic outreach within 5 days of an inpatient hospital stay to ensure that the discharge was appropriate, that members have scheduled follow up appointments, and that members understand their discharge instructions including newly prescribed medication. For our Medicare members ages 65+, we offer a special 30-day Readmission Prevention Program that includes frequent contact and a home visit from a Nurse Practitioner for those residing in Milwaukee, Kenosha, Racine, Waukesha, and Ozaukee counties. For members under 65, we have relationships with home health agencies in counties across the state to conduct a 90-day readmission prevention program.
Are you concerned that SDoH are the reason for your patient’s readmissions? Please follow up with a member of our staff to discuss your concerns by calling our Customer Service line at
High-Risk Disease Management
As members continue to struggle with SDoH, management of their diagnoses can become increasingly difficult. iCare has specialized teams for our Medicare and Medicaid members whose risk stratification assessment has identified them as high-risk. These teams have decreased caseloads and, if appropriate, will conduct home visits throughout the member’s enrollment in the program. Referral criteria can include: increased inpatient/ED utilization, active SUD, untreated mental health diagnoses, recent suicidal/homicidal ideation without evidence of established providers, and pregnancy with active SUD or untreated mental health diagnoses.
Do you have a member with SDoH concerns that would benefit from high-risk disease management? Please reach out to the assigned CC or RNCM by calling our Customer Service line at
Additional Benefits and Community Partnerships
In addition to the specially trained staff and programs available to our members, we’ve also developed relationships with organizations addressing health disparities in the communities we serve. As previously mentioned, homelessness and homelessness prevention are a top priority at iCare. We’ve streamlined a referral process with Guest House of Milwaukee that ensures our members have the best chance of success at obtaining and maintaining stable housing. We’ve partnered with Social Development Commission and their Senior Companion program to assist our members dealing with social isolation. Lastly, we have enhanced our benefit package to include coverage of certain over-the-counter items and gym memberships to name a few.
While significant progress has been made to recognize and address social determinants of health, challenges remain. How is your organization addressing SDoH? What partnerships have you developed in your community to assist your patients struggling with SDoH concerns? Are there any entities you’d like to see iCare partner with? Supporting each other as we assist our mutual patients/members struggling with SDoH is one way we can serve our community well.
References: About Social Determinants of Health (SDOH). (2020, August 19). Retrieved January 28, 2021, from https://www.cdc.gov/socialdeterminants/about.html