In order to keep senior citizens out of the hospital and emergency room, Medella Healthcare provides In-Home Care Management as part of the program. Our Care Managers (licensed LPNs, RNs, License Social Workers, Geriatric Care Manager or Certified Care Manager) act as advocates and coordinators to help members access benefits and resources and as coaches to assist with disease management, self-care, medication reconciliation (to help avoid medication confusion), and identification of gaps or barriers to care (without providing direct care themselves).
Our Current Programs
We currently offer 3 programs for our employees to provide care to our Members:
- In Home Survey Program (IHS)
- Transitions Program
- Long Term Program
In Home Survey Program (IHS)
This program is a single in home visit; it is used to engage members in their homes and to identify and evaluate any problems that need to be solved. This visit is conducted to conclude areas of focus, any barriers that the member may experience, as well as to determine what the next steps are to obtain a healthy lifestyle.
The 30 day Transition Program consists of two (2) in person Care Management visits with the patient, coordination with PCP and telephonic contact to ensure adherence to the treatment plan.
Long Term Program:
This program is a long term plan to ensure the member stays healthy and out of the hospital. This program allows for 4 in home visits per month to check up on your members as well as to ensure they are following the proper instructions and devised care plan. The program is usually for high risk members who need an abundance of care coordination. This program allows each member the option to continue receiving weekly assistance throughout the duration of their life span.
Outcomes at 30 days:
- Patient will have the means to obtain medications, understand what medications to take and how to take them.
- Patient will understand self-care requirements and be able to implement them.
- Patient will have access to helpful resources if needed.
- Patient will be able to continue PCP follow- up as required.
- Patient will be able to remain at home and avoid unnecessary hospitalizations.
1. A referral is made to Network from an onsite Care Manger at the hospital. 2. Within 48 hours of the discharge, an Medella Healthcare, Care Manager will visit the patient at home and complete the Focused Assessment. During the visit the Care Manager will gather information and educate the patient on his or her diagnosis management, medication administration and home stay in order to prevent a readmission. The Care Manager coordinates and helps to schedule an appointment for patient to see PCP within one week of discharge from hospital. The Care Manager will assist the patient and or family to connect with other needed resources such as meals, transportation to PCP and insuring that all prescribed medications are in the home. 3. The Care Manger enters the assessment and visit information into the Network /Medella Healthcare electronic health record system within 24 hours of the home visit. 4. Medella Healthcare ’s Director of Nursing (DON) reviews the assessment and care plan, consults with the CM in order to approve the plan. At all times the Medella Healthcare DON is available to Care Managers as a resource. 5. The Care Manager provides care coordination and makes periodic phone calls to the patient during the 30 day time period to insure adherence to the plan. 6. The Care Manager is available to answer questions from the patient during the 30 period. 7. All activities related to the patient are to be documented in our electronic data base for assessment and billing purposes.
Medella Healthcare, LLC. Required Documentation
All documentation required by the Medella Healthcare, Care Manager(s) is very important to be completed and entered into our electronic data base in an approved manner as it directly affects our company’s ability to bill for the required visits and pay the Care Manager in return. The correct entry of information into the electronic data base will be covered during the Care Manager training. 1. The data base is a secure and confidential site. 2. Each Care Manager will complete an assessment of their client. 3. All documentation regarding patient visits must be entered into the electronic data base. 4. A version can be printed out from the electronic site to be taken to the client. 5. All notes and recommendations by Care Manager entered into the electronic data based are reviewed by Medella Healthcare’s DON (Director of Nursing).