Helping to Ease the Transition from Hospital to Home

David, 72, Humana Medicare Advantage member, has been healthy most of his life. He’s lived a healthy lifestyle, eating healthy foods, running for exercise and lifting weights. Recently retired, David says that his ‘health has taken a bad turn ever since.’ 

David’s history is complicated. In 2014, he was diagnosed with prostate cancer. The following year he underwent brachytherapy, a type of internal radiation therapy in which seeds containing a radiation source are placed near the cancer, for treatment. 

As routine care and a preventive measure, David and his physician closely monitor his prostate-specific antigen (PSA) level through blood tests to check for possible concern of the cancer returning. When David’s PSA levels started to go up eight years later, it was apparent that something had changed.

David’s doctor ordered more tests. which revealed David had developed colon cancer. During surgery to remove a portion of the bowel, David received a temporary colostomy which would collect stool and allow his body to heal during recovery. When he was discharged from the hospital, David had a peripherally inserted central catheter, more commonly called a PICC line, through which intravenous therapies and fluid could be administered.

Tony Doyle, RN, a care manager with Humana Care Support, called David once he got home from the hospital to check on him. David was feeling nervous about the PICC line and fearful of becoming dehydrated. Tony’s support was very welcome.

“He was so grateful that Humana thought so much as to have me call him to make sure he understood his discharge instructions and to assist with any concerns he might have,” said Tony. 

Humana Care Support is made up of an interdisciplinary care team focused on improving the physical, social and behavioral health of members by providing evidenced based clinical and personalized interventions so members can age in place and achieve their best health. The team’s primary focus is to reduce inpatient admissions and prevent readmissions once members have been discharged from an inpatient setting.

Tony talked with David about his PICC line and how to care for it. He let David know that someone from a home health agency would be assisting him with flushing the line and any necessary dressing changes. David would need to keep the PICC line in place for several weeks while he received intravenous antibiotic treatment.

Tony taught David about dehydration and how to conduct the ‘skin pinch’ test on the back of his hand to detect dehydration and encouraged him to drink plenty of water. Tony also told David about Mom’s Meals, a benefit included on David’s Humana plan that provides nutritious, ready-to-heat meals to members after hospitalization, and about the option to select Cancer Support meals.

“As we finished our conversation, David expressed his relief,” said Tony. “He told me that he was lucky to have a family that supported him completely, a staff of doctors that he knew he could trust and to have me as a nurse to help answer his questions.”

“I’m glad to know that if I have questions, all I need to do is call Tony,” said David.

Tony reached out a few days later to David to discuss his medications, ask how his follow-up appointment with the surgeon went and to offer further support. 

But when he called, David’s wife answered the phone and shared that David was outside doing his exercises. Tony offered to call back at a better time. “Oh, No! He will want to talk to you,” she said before retrieving David to come to the phone. 

“He spoke to me like we’d been lifelong friends,” said Tony. “I commended him on walking for exercise and asked about how his appointment went earlier in the week.”

David reported that the surgeon removed his staples, assessed his incision and told him the labs that were recently drawn were great. He was excited to share that he will go back to see his oncologist soon, then will visit his surgeon in around six weeks to look at reversing his ostomy.

“David was so complementary about the education I had provided and wanted me to know how much it reduced his stress after we spoke earlier in the week,” said Tony. “He shared that the things we'd discussed were exactly what his surgeon had spoken to him about at his visit.”

David expressed sincere gratitude to Tony and thanked him for his help and for being available to answer questions and offer guidance. Without further questions or concerns at that time, David said that he would call if he needed something in the future.

Tony followed-up with David about two months later to see how he was doing. David was happy to share that his colostomy reversal surgery was successful and that his recuperation was going well. “It gets a little better every day,” David said.

“I am thankful to be able help our members,” said Tony. “Humana makes a difference simply by having us call members at important times, such as after hospital discharge, to ensure that their needs are met and questions are answered.” 

“David told me how much the call helped to reduce his stress.” Tony said, “I am so excited that I had the opportunity to call him, and I know Humana made a huge impression because he told me so.”

Your results may vary. It may not be typical to improve health conditions by taking the actions David did. Consult your doctor before beginning any new diet or exercise regimen.

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