Neighborhood’s New Home-Based Care Program for Highly Complex and Costly Members Shows Strong Initial Results

PROVIDENCE, RI – Neighborhood Health Plan of Rhode Island (Neighborhood) today reported favorable initial results on its new Health@Home program to disrupt the cycle of high risk and high cost for its most complex members. Health@Home participant claims data show Emergency Room visits have been reduced by 26 percent and medical inpatient days have been reduced by 30 percent when compared to their medical usage over the same time period the previous year. The Health@Home program is expected to grow to serve 450 members and save at least $2.7 million in net expenses during 2015, its first year of operations.

Health@Home delivers Neighborhood-staffed primary care at home for a limited time until the “frequent utilizer” member stabilizes and reconnects with their regular doctor. Neighborhood records show an average “frequent utilizer” member accounts for $58,000 in medical costs per year through seven emergency room visits, at least two hospital admissions and nearly two dozen prescriptions.

“We know from our work with EOHHS that 7 percent of Rhode Island Medicaid enrollees account for approximately sixty-six percent of program spending, costing the state over 1 billion a year,” said Dr. Trilla. “For this group, routine clinic-based care is often not effective due to complex medical, social and behavioral conditions. This lack of routine care can lead to frequent preventable emergency room visits, hospitalizations and inappropriate medicine usage.”

Members voluntarily enroll in Health@Home and receive an initial assessment of their medical, social, psychological and pharmacological needs. Each member works with an interdisciplinary health care team to create a personal plan of care and address life goals. Members can access their team twenty-four hours a day, seven days a week, through in-person and telemedicine interactions. There is great flexibility for members to receive a wide array of appropriate patient-needed services.

“Each interdisciplinary health care team is led by a nurse practitioner and includes community health workers and a social worker,” said Alison Croke, Health@Home’s Director. “During a member’s participation in Health@Home, the team works to identify the barriers to primary care, and how to best address them. Examples of barriers might include lack of transportation, motivation or education. The goal is to have a member ready to transition back to office-based primary care within six to twelve months and help them regain some control over their health care.”

On average, members enrolled in Health@Home receive two to three home visits per month. Each of the community health workers are Certified Nurse’s Aides or Medical Assistants, capable of performing certain routine clinical functions. Each week, the mobile clinical team meets and “rounds” on members. These “rounding” meetings include representatives from other areas of the health plan including the pharmacy team, and nurse case managers.

To qualify for Health@Home, Neighborhood members must meet the following criteria:

  • Member is over the age of 21 and fully eligible for Medicaid
  • Member is only eligible for Medicaid (not Medicare also)
  • Member does not reside in a nursing home, or other long-term institutional setting.
  • Member has more than $25,000 in medical expense during the most recent 12-month period.
  • Member has had more than two inpatient stays and/or more than two ER visits in the previous 12-month period.
  • Member is not taking more than two opiate prescriptions (opiate seeking members are not appropriate for program referral).
  • Member has one or more of the following chronic physical conditions:
  • Diabetes
  • Asthma
  • Congestive Heart Failure
  • Chronic Obstructive Pulmonary Disease
  • Hypertension
  • Member may have co-occurring behavioral health conditions that include anxiety, depression and mood disorders.

Health@Home is based on national models, including the Veterans Administration home-based primary care program, which have demonstrated savings and reduced utilization in inpatient admissions, emergency room visits and skilled nursing facility admissions.

“Governor Raimondo and Secretary Roberts have been effective in leading the effort to find ways to improve health outcomes and reduce costs for challenging Medicaid populations,” said Peter Marino, President and Chief Executive Officer for Neighborhood Health Plan of Rhode Island.  “We offered Health@Home as a program policymakers could build upon and believe it will prove to be an effective initiative to help control costs while ensuring high quality care to Neighborhood members.”

About Neighborhood

Neighborhood Health Plan of Rhode Island is a non-profit HMO that was founded twenty years ago to make sure everyone in the state has access to high-quality, low-cost health care. Neighborhood has been ranked as one of the top ten Medicaid health plans in America for the past eleven years and serves more than 170,000 members. In January 2014, Neighborhood extended its great service, benefits and value to individuals and businesses through HealthSource RI – the state’s health insurance exchange. For more information visit

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