Here are some examples of how our in-home care program has helped chronically ill seniors

Blue Cross Blue Shield of Michigan recently announced it’s expanding a program to provide in-home care for chronically ill senior members. The program first launched in October 2021 for UAW Retiree Medical Benefits Trust Medicare Advantage members, using the services of Landmark Health L.L.C., an independent company that provides Blue Cross with care management services. With the expansion, the program will become available to more than 85,000 of our Medicare Advantage members across the Lower Peninsula.

Using a physician-led, interdisciplinary team, the program complements office-based primary care with such services as care management, behavioral health, medication management, 24/7 nurse triage and urgent care. The model also builds in community health advocates to support the member. It turns a potential multiweek medical episode into a treatment plan that cares for a member in his or her home.

To learn more about our program with Landmark, read the article “We’re expanding our in-home care program for seniors with multiple chronic conditions,” also in this edition of the newsletter.

Success stories
Here are some examples of how the program helps members:

T.S.*

A 66 year-old, male, T.S. had a left-sided stroke about one year ago. He spent four months in a coma and required feeding tubes, ventilation and tracheostomy. He also has high blood pressure and high cholesterol.

T.S. has recovered significantly, but continues to have memory difficulties, minimal right-sided weakness and dyskinesia. 

Part of Landmark’s treatment plan is to work with T.S. and his care team to address intermittent dizziness and orthostatic hypotension, and coordinate medications and care with his primary care provider and specialists. Landmark reports T.S. is healthy and stable. He told Landmark he hasn’t had any episodes of dizziness or falls since working with Landmark.

B.C.*

B.C. is an 87-year-old female who lives with adult children in the same house, though she provides more care for them than they do for her.

She contacted Landmark after receiving a flyer introducing her to the program and decided to call because she didn’t want to go to the emergency department. She was suffering from bladder infection and had been treated by her primary care provider with antibiotics but was not improving as quickly as she hoped.

Landmark visited BC on back-to-back days. During the initial visit, it was determined that B.C. had been prescribed antibiotics days before but hadn’t been taking them as directed. She was evaluated for signs of worsening infection, such as sepsis or kidney involvement, but no additional concerning symptoms were found. B.C. called the next day due to unusual nausea and vomiting. During the second visit, she was treated with anti-nausea medication. Urinalysis was completed in-home. A Landmark physician contacted BC’s primary care provider for a physician-to-physician discussion regarding the treatment plan.

Urinalysis showed her bladder infection was improving and that continued treatment following the current course of antibiotics was appropriate. B.C. was contacted by Landmark several times over the following days to monitor progress and avert an unnecessary ER visit.

F.J.*

F.J. is a is a 72-year-old male who is non-compliant with his medication regimen and complains of shortness of breath. He has Type 2 diabetes, which requires insulin, hypertension, chronic obstructive pulmonary disorder and morbid obesity. F.J. said his goal is to get “back to a normal routine without shortness of breath.”

In December 2021, he was discharged from the hospital and treated by several specialists who had prescribed two inhalers, Trelegy and Albuterol. F.J. said he didn’t know how to take his medication — and why it was needed — and that he didn’t like them because they didn’t make him feel any better. He was using a nasal spray (Afrin) and Primatene mist instead.

Landmark discussed F.J.’s plan of care with the multidisciplinary care team and determined that a nurse care manager would follow up with a call to him in two weeks to continue education and support.

Landmark provided F.J. with extensive education about his medical conditions, specialists and the importance of using his medications as prescribed.

“I see all of these doctors and they are all doing different things,” F.J. said. “Marcia (Landmark APP) came in and I got more education from her than all these specialists! She put it in layman’s terms and I was able to understand everything for once. I am very appreciative of the Landmark team, the education and the time spent with them. I am looking forward to the next visit.”

*Abbreviations used to protect the identity of the member. Member stories are shared with permission.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.