Follow to Home (F2H)
Question: When is a member at a high risk of being readmitted?
Answer: When the member has just been discharged.
The Follow to Home program does just as the program name implies: iCare coordinates with home health agency nurse case managers to follow the member home. They provide support and education to help the member and his/her friends and family better understand the strategies and techniques to avoid ending back up in the hospital.
Key elements of the program include:
- Readmission Risk Assessment (RRA) conducted upon discharge.
- Home health agency RN call or visit as soon as possible post discharge when RRA score is high or medium.
- Ongoing home visits and telephonic support are provided for 90 days.
The result: over the crucial next thirty days, approximately 90% of Follow to Home program participants are able to avoid re-admission.
Follow to Home for Homelessness (F2H4H)
After seeing Follow to Home demonstrate a high-level of success, we asked ourselves another question: What if the member doesn't have a home?
iCare is committed to working with our members who are homeless. As such, we created Follow to Home for Homelessness (F2H4H). F2H4H assists members discharging from area hospitals who are homeless and in need of skilled nursing care, post-discharge. Hospital social workers can contact iCare’s RN Discharge Planners while the member is a hospital inpatient. This will help the iCare team to attempt to visit the member (while inpatient) to develop a plan that can assist in finding a safe and clean location to allow for skilled nursing care.
The goal is to develop a post-discharge plan, which includes case management and community-based nursing care. The post-discharge plan may also include services provided by community-based organizations (CBO) who can provide a clean, safe and comfortable environment for visits with the home visiting nurse. These CBOs will have proven expertise in working with this population. Care is administered anywhere an iCare member prefers — at CBOs, social centers, shelters, or faith-based organizations, as well as in their tent encampment, alongside the river, or anywhere else the member will allow.