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Meals, home telemonitoring available to heart failure patients
February 12, 2019

This article is intended for cardiologists, licensed dietician nutritionists, primary care providers, and discharge planners at acute care hospitals, rehabilitation hospitals, and skilled nursing facilities.

We’re accepting referrals for Medicare Advantage members with congestive heart failure to participate in our latest offerings—a nutritious meal program and home telemonitoring.

Both pilot programs are designed to keep members who have been recently hospitalized with congestive heart failure out of the hospital and living healthy lives at home.

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Healthy meals program

Our latest innovative pilot program for members with congestive heart failure focuses on diet and good nutrition.

We are collaborating with Community Servings, a not-for-profit food and nutrition program for people living with critical and chronic illnesses. Community Servings will provide eight weeks of medically tailored, nutritious meals, plus nutrition care services from a licensed dietician nutritionist.

Since a low-sodium, low-fat diet is so important when managing congestive heart failure, we believe this program can help educate the member so that they stay out of the hospital. The program will also reduce barriers for members who face difficulties in obtaining and preparing healthy foods.

We are now accepting referrals for members with a recent inpatient stay. We may expand the program to cover additional diagnoses, based on outcomes.

Who is eligible?
You can begin referring Medicare Advantage members if they have:

  • A congestive heart failure diagnosis within the last 18 months
  • A recent admission to the emergency department, or an inpatient or observation stay at the hospital within the last seven days
  • Difficulty with meal preparation and could benefit from having diet-specific meals delivered to their home because they don’t have other help with meals
  • Live in an area where Community Servings delivers (see their website for coverage area)

There’s no additional cost to the member when they meet the program criteria.

How does it work?
Once we identify a member (or receive a referral from the member’s provider), we will contact the member to make sure they meet our criteria, and that they are interested in the program. Then, we’ll work with Community Servings.

A Community Servings registered dietician will then contact the member. They’ll review the referral and select an appropriate diet that meets the member's dietary needs (including any dietary modifications). Community Servings will let the member know their weekly delivery date for the meals. The member will need to be home to receive them.

Meal delivery from Community Servings typically lasts eight weeks. The primary care provider will receive a letter notifying them that the member is participating in the meals program. The Blue Cross case managers will continue to follow the member by phone with periodic check-ins.

In-home telemonitoring program

We also offer Medicare Advantage members with congestive heart failure a home telemonitoring program in conjunction with several home health providers in our network. Learn more about the program.

How can you refer a Medicare Advantage member for healthy meals or in‑home telemonitoring?

There are two ways:

  1. Contact Blue Cross Blue Shield of Massachusetts registered nurse, Kerry Nussbaum, at 1-617-246-4721.
  2. Fill out the Referral for Health Management Programs & Services form. Check off Medicare Advantage Case Management and note the reason for the referral in the notes section. Please fax to the Medicare Advantage number listed on the form.
Learn how in‑home telemonitoring helped one of our members

A grandma takes charge, thanks to our telemonitoring program

Patricia Grogan didn’t feel quite right.

The 80-year-old grandmother was short of breath, had swollen ankles and had gained more than 10 pounds in a week — telltale signs of congestive heart failure.

CHF is a dangerous condition in which the heart can’t pump blood efficiently, depriving the body of oxygen and other nutrients.

That set off alarm bells for Blue Cross Blue Shield of Massachusetts nurse case manager Julie Aubin, who called Grogan last November for a routine follow-up conversation as part of her regular health plan. After hearing her patient’s symptoms, Aubin knew she needed to act fast.

Aubin told Grogan to call her doctor immediately and ask about increasing her diuretic medication. 

She also recommended Grogan join the telemonitoring program the health plan had recently launched for Medicare Advantage members with CHF — one of the first insurance carriers in Massachusetts to offer such a program. 

The telemonitoring program provides members like Grogan with simple “smart” equipment, including a scale and blood pressure cuff to use each morning. The equipment automatically sends the member’s vital signs to a visiting nurse, who monitors the numbers and can catch any potential problems early. The nurse communicates and coordinates with each member’s primary care physician and cardiologist as appropriate.

Read the full story about how Blue Cross’ telemonitoring program helped Patricia Grogan and her doctors manage her heart condition.



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