Healthy At Home

Program Information
Tejas Healthy at Home is a care transition program developed to support individuals being discharged from a hospital or other higher level of care and is designed to decrease their probability of readmission. Those members who suffer from a health condition that can be successfully addressed in the community are eligible for entry into the program.

The program uses non-professionals who are trained as Transition Coaches to provide all direct member services.

Upon referral of a case from Tejas, the local provider organization assigns a Transition Coach to engage the member and determine suitability for admission to the program and their interest in receiving the service.

Admission to the program is determined by the following qualifying criteria:

  • Member is covered by a participating insurance carrier
  • Member plans to be discharged to their home, to assisted living, to a friend or family’s home, or to some other non-institutional / non-medical community setting
  • Member is willing to enter the program

Following the hospital visit, a Transition Coach typically visits the member in their home. The Home Visit normally occurs within the first 72 hours following discharge, but usually no later than one week after discharge. During the home visit, the Coach conducts an environmental safety evaluation and a medication review. After completion of the home visit, the Coach stays in touch with the member, contacting them at least weekly to check on progress and any factors that may affect their ability to remain out of the hospital. As needs are noted, the Coach ensures that appropriate actions are taken to reduce the risk of readmission. Most members are followed for 30 days following their discharge from the hospital; in certain circumstances, case management can be extended with approval from Tejas and the health plan.

Interventions Involved
Tejas Healthy at Home is based on Dr. Eric Coleman’s Care Transitions Intervention™ (CTI).

This program, which emphasizes coaching, is a non-clinical intervention, and points the member back to clinical follow-up as needs arise.