Humana Serves the Whole Person through Team-based, In-Home Care
Belle, a Humana provider, brings engaging foot care right to the home of Medicare Advantage members. Over a third of seniors can no longer reach or see their feet. Left uncared for, feet can develop serious complications and inhibit a healthy and happy life.
In particular, preventive foot care is incredibly important for those with chronic illnesses like diabetes, neuropathy and vascular disease. These conditions drive over a million preventable foot complications each year – a key reason why Humana found it important to provide this service to its members.
However, Belle foot appointments were not only designed to protect mobility, but to bring joy into members’ lives. Their monthly 60-minute appointment is a time when members can sit back, relax and experience a social visit with their Belle Technician, who often becomes a friend. “Ultimately, this program’s purpose is to serve the whole person” says Caraline Coats, VP, Population Health Strategy, Humana. “This is not only the right thing to do, but a fantastic care delivery innovation for improving physical, mental and social health.”
An 82-year old man who enrolled in the Belle program in December 2019 is a great example of that mission being fulfilled.
Belle’s first appointment with this gentleman was routine and he was happy to have the service: “I need help and my kids are spread across the country… They have their own families and they can’t just drop everything to come here!” His feet were showing signs of stress from his chronic conditions, but no emerging warning signs. However, foot health becomes volatile as we age and Belle’s next appointment earlier this year demonstrated just that. As the Belle Technician, Noreen, began her assessment (assisted and captured with cloud-based mobile technology), she documented extensive and severe scaling and inflammation on both of his lower legs and feet.
Noreen also noticed that her member seemed considerably disoriented, which was a significant change from her last appointment. As trained, she documented and photographed the condition of the member’s feet as well as his new mental progression. “We think of the members we serve as our own mom or dad. We are always thinking about what we want Humana or their PCP to know so we can get them the care or resources they need,” says Noreen, Belle Technician.
Armed with longitudinal photos and documentation, Belle’s clinical team was able to seamlessly step in and begin a deeper assessment. They were immediately able to speak with the member’s son. He agreed that his father’s growing confusion was a new development. Admirably, he had attempted to get his father to seek medical attention without success. In fact, their relationship became strained and his father dismissed him as his caretaker and even refused to take his medication.
After understanding the environment and relevant stakeholders, Belle’s clinical team and technician were able to delicately influence a visit to his PCP, who was provided all the necessary documentation. “This case is exactly why I became a social worker,” says Morgan Rook, Belle team member. “We do whatever it takes to care for the whole person and that usually means connecting the community together for a common purpose.”
From there, his PCP and the Humana provider network sprang into action. The member was admitted to the hospital for treatment of severe cellulitis, which was an exacerbation of his peripheral vascular disease. He was also diagnosed with an urinary tract infection. It was discovered that these infections were causing his temporary disorientation. His disorientation, in turn, was causing social isolation, lack of medication adherence and more- all creating endless negative feedback loops on his wellness. Together, his network of providers and Humana were able to break this cycle.
As an added challenge, the COVID-19 crisis began just as the member was released from the hospital in March. This was a dangerous situation. Without proper oversight, this member could easily regress. However, Belle established continuity of care, connecting this vulnerable member to critical preventive services.
With PPE and enhanced sanitation precautions, Belle continued to make home visits to provide foot health and document his recovery. Belle became the eyes and ears of his care team, communicating whenever there was a change in status. Through the pandemic, the Belle appointment has served as a social oasis when even more seniors are suffering from isolation.
Three months later, this member was feeling much better. “[My feet] are a lot better than they were!” he says. “Send Noreen again. She is very good!” His infections and other issues have improved considerably and Noreen continues to look after his well-being. “This serves as a powerful case study on how innovative team-based care, strong member relationships and thoughtful technology worked together to improve outcomes in a difficult environment,” says Rufus Howe RN, Belle’s Chief Product Officer. “As always, we are proud of our partners and our ability to collaborate.”
Belle provides engaging and health-promoting foot care services to health plan members in their homes. The following story highlights a typical intervention we manage through our Belle Technicians and clinical team who collaborate every appointment. Our appointments are guided by evidence-based protocols. Trained to perform a comprehensive assessment and make careful observations, the Belle Technician records each element of the visit in our mobile platform. Using embedded logic, the platform will prompt our clinical staff to review the appointment for emerging clinical and social determinant issues. Once validated by the Belle clinical team, the PCP, podiatrist, or case manager will receive a visit summary and request for further evaluation and treatment.
Being in the home is a powerful extension of both the PCP and health plan. This story is a product of proper targeting, trained Belle Technicians, timely clinical review and communication.