As a patient, one of the most tenuous experiences is being admitted to a hospital. In the course of treating the condition and heading toward recovery, patients are often seen by several different providers – many of whom have never seen the patient before.  In addition, patients undergo various procedures and are subjected to transfers between units or even facilities. Upon discharge, patients and their families receive various, often complicated instructions, which they are expected to retain and then carry out at home.  As an example, a typical Medicare patient could be given a handful of new prescriptions to fill along with educational materials related to the condition, reminders of appointments to make within the coming weeks, and various referrals.

With so much to juggle, it’s no wonder patients have a difficult time properly managing their care when released from the hospital. In fact, many of them – about one-fifth of Medicare fee-for-service patients – end up back in the hospital within the first 30 days.  However, many of these readmissions can be prevented with the support of an integrated care coordination team. 

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At DaVita HealthCare Partners (HCP), there are interdisciplinary teams dedicated to coordinating care for the patient to ensure a smooth and safe transition from hospital to home.  DaVita HealthCare Partners’ Hospitalists, physicians who meet with patients and families while in the hospital, are the eyes and ears for the patients’ Primary Care Providers.  These inpatient physicians work closely with Nurse Care Managers.  Together, they are accountable for ensuring the patient is discharged at the right time, to the proper setting, and with the appropriate resources to prevent an avoidable hospital readmission. 

Inpatient Care Advocates are also part of the team, and they are responsible for gathering pertinent clinical information and ensuring that patients are reconnected with their Primary Care Providers.  After being released from the hospital, every patient receives a phone call from an HCP Advocate, confirming that patients know what medications to take, helping them schedule their next doctor’s appointment, and making certain they have all the information they need.  At DaVita HealthCare Partners, we call this team “I-CARE” or Inpatient Care Advocates Redefining Excellence.  Further collaboration and support is provided by social workers, pharmacists, and educators.  For patients who need extra attention, DaVita HealthCare Partners has designed unique care coordination programs that can provide in-home visits by nurse practitioners, comprehensive care visits with a focus on advance care planning, or palliative care consultations.   These services are available to all patients, 24 hours a day, 7 days a week, as DaVita HealthCare Partners runs a Patient Support Call Center staffed with nurses who can direct and coordinate care at any time.  Most importantly, though, all of these programs and departments work in concert with the patients’ Primary Care Providers.  Therefore, patients can rest assured that every aspect of care is, in fact, completed with his or her best interest in mind.

CMS’ Medicare Advantage program provides DaVita HealthCare Partners with the resources to build this robust care coordination infrastructure, allowing us to deliver effective care to patients in the most vulnerable times of their lives.  We are able to staff multidisciplinary teams, consisting of the expertise needed to provide high quality and comprehensive care to our patients.  We are able to invest in technology so we can share patient information and communicate effectively with each other. We are able to innovate, creating new ways to deliver care to patients based on their distinctive needs.  It is because of these programs and resources that only 16.1 percent of DaVita HealthCare Partners senior patients nationwide are readmitted to the hospital within 30 days of being discharged compared to 18.5 percent of Medicare FFS patients.  In California, the HCP senior readmission rate was 14.2 percent last year.  While these metrics are impressive, one of the 2015 nationwide initiatives for the DaVita HealthCare Partners enterprise is to further enhance our processes for patients’ transitions from hospital to home and reduce any additional unnecessary readmissions.  We want to improve the hand-off from hospital to clinic and encourage our Primary Care Providers to see their post-hospitalized patients within seven days of discharge, and in many instances, sooner.

Surprisingly, despite the Medicare Advantage program’s widespread popularity and measurable success for both patients and taxpayers, Congress has repeatedly gone after this vital program with cuts that threaten its integrity and long term sustainability. Ultimately, bolstering Medicare Advantage in order to support innovative care coordination, quality patient outcomes and lower healthcare costs is a vital step for patients everywhere.

As we enter this new legislative session, Congress should listen to both seniors and our nation’s caregivers on the front lines of care, who are witnessing the extraordinary benefits Medicare Advantage offers. They must protect this program from additional cuts and should invest to improve payment accuracy for high cost individuals.  If Congress does not believe what they are hearing, then the measurable results like the ones we are seeing at DaVita HealthCare Partners should speak for themselves.  

Jung is the national chief medical officer for HealthCare Partners Medical Group.