Pulse
Group Effort
A hospital, medical group, and payer work together to keep patients from needing to be rehospitalized.
By Carmen Peota
A year ago, Barry Baines, M.D., associate medical director of UCare, approached Fairview Physician Associates’ chief medical officer, William Nersesian, M.D., M.H.A., about the high number of Medicare patients who were being readmitted to hospitals for reasons that were avoidable. Sometimes, patients hadn’t filled prescriptions because they couldn’t afford them. Some never saw their primary care doctor for follow up because they didn’t have a ride to the clinic. Others weren’t eating right. “It’s not that a patient with heart failure went home and developed a rare or new condition,” Nersesian says. “Most patients who come back to the hospital do so because of something that could have possibly been foreseen.”
So the leaders of the health insurance company and the physician group sat down to talk. They quickly realized that all of the players involved in these patients’ care needed to be involved if they were to reduce readmissions. They designed and last February launched a program for patients enrolled in UCare’s Medicare Advantage plan.
The gist of it is plain old teamwork. Achieving that, however, has taken some forethought. Key components are having a pharmacist from the hospital spend time (above and beyond what Medicare requires for medication reconciliation) with the patient talking about their medications; a nurse case manager identify problems that might interfere with the patient’s recovery and call the patient within two days of discharge to make sure they get to their primary care doctor for follow up; and a primary care physician see the patient within five days of discharge. In addition, the hospital provides a discharge summary to the patient’s primary care physician within two days of discharge. UCare pays physicians a $50 bonus (beyond the amount Medicare pays for a hospital follow-up visit) when they see patients within five days.
Nine months into the project, the number of readmissions at Fairview Southdale Hospital was down by 30 percent over last year. This year, the approach is being extended to Fairview Ridges Hospital in Burnsville. And Nersesian and others are sharing what they’ve learned through an Institute for Clinical Systems Improvement collaborative. ■