Nonclinical, transitional care program aims to reduce readmissions for Medicare Advantage members

Blue Cross Blue Shield of Michigan and Blue Care Network are contracting with naviHealth to reduce avoidable inpatient readmissions through a nonclinical, transitional care program.

This program will be available to Medicare Plus Blue℠ and BCN Advantage℠ members who are discharged from inpatient facilities in Michigan, and will be implemented in two phases:

• On Nov. 1, 2021, the program starts for Medicare Advantage members who are discharged to certain post-acute care facilities in Southeast Michigan. (We piloted this program starting in April 2021, as communicated in a May Record article.)
  
  Note: To learn which post-acute care facilities are included in this program, email Lana Davis at ldavis8@bcbsm.com.

• On Feb. 1, 2022, the program starts for Medicare Advantage members who are discharged directly to their homes.

naviHealth staff will support these members as they transition out of inpatient facilities. These efforts will extend for up to 30 days after members are discharged. With each interaction, naviHealth staff members will introduce themselves to the member, using their name and licensure (if applicable) and the naviHealth name.

Prior to discharge from an inpatient facility

naviHealth navigation specialists will work with members prior to discharge from an inpatient facility to:

• Discuss the member’s current health and whether the member feels he or she is ready to be discharged.
• Identify social determinants of health through naviHealth’s proprietary technology.
• Address barriers to continuity of care.

The navigation specialists will share this information with the naviHealth patient navigator who is assigned to the member for post-discharge care.

After members leave inpatient facilities

naviHealth patient navigators will work with members after discharge from inpatient facilities to:

• Review members’ discharge needs.
• Educate members to achieve better outcomes based on the discharge plan.
• Create a plan to address any health barriers members may be facing.
• Assist members in overcoming barriers that were identified prior to discharge. This may include scheduling appointments, coordinating care or connecting members to community resources to address social determinants of health.
• Assist members with medication adherence.

If the patient navigator has concerns about a member, he or she may reach out to the member’s provider.

Note: Patient navigators are commonly known as community health workers. These naviHealth staff members are trusted, knowledgeable frontline personnel who typically reside in or near the communities they serve.

Additional information

For more information about this program, see the Readmissions Reduction page on naviHealth’s website.**

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.