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.