Contact: Brenda Jaye,  Fairview Physician Associates, 952-914-1858
                Wendy Wicks, UCare, 612-676-3567

Edina (February  15, 2010)—A group of Medicare Advantage patients admitted to Fairview Southdale Hospital during 2010 will benefit from a pilot project to keep them from returning unnecessarily to the hospital. Fairview Physician Associates (FPA), UCare and Fairview Southdale Hospital have teamed up to improve patient care and experience, and reduce costs.

“Nationally, 20 percent of hospitalized Medicare patients are readmitted within 30 days of discharge,” says William Nersesian, MD, MHA, chief medical officer, Fairview Physician Associates. FPA is an Edina-based network of 1,200 independent, Fairview employed and University of Minnesota primary and specialty physicians.

“We recognize that some readmissions are unavoidable. However, preventing avoidable readmissions keeps patients healthy and holds costs down,” he adds.

Swift follow up with patients is key to preventing avoidable hospital readmissions, says Barry Baines, MD, associate medical director, UCare. UCare is an independent, nonprofit health plan serving 200,000 members enrolled in Minnesota Health Care Programs and Medicare across Minnesota and western Wisconsin.

"This pilot holds great promise to help our Medicare Advantage patients with chronic conditions experience a rapid and uncomplicated recovery after discharge."

For example, a patient with diabetes and heart failure returns home after a hospital stay for shortness of breath and heart-failure related weight gain. At home the patient may not have a family member available to help him take his medications correctly, eat the right foods and weigh himself to check for fluid retention. He could miss warning signs that might quickly land him back in the hospital.

Each prevented readmission will keep patients healthier and could save at least $5,000 per patient, Dr. Nersesian says.

“This pilot is designed using evidence-based data to reduce variation and establish standardized processes,” says Dr. Nersesian. “We hope to see a 20 percent or more drop in preventable readmissions to the hospital,” he says, “but we will welcome any progress, and will share our learning with the system.”

As of Feb. 1, UCare provides an incentive to FPA primary care providers to see UCare for Seniors Medicare Advantage patients within five business days of discharge from Fairview Southdale Hospital. The group includes about 12,500 patients, many with diabetes, heart failure and chronic obstructive pulmonary disease. During the post-discharge clinic visit, the health care provider will make sure that patients are correctly taking the right medications, understand what is necessary for good health and what to do if problems arise.

Other interventions include:
*FPA nurse case managers follow up with discharged UCare for Seniors patients in the hospital and by phone to make sure they understand their medications and how to take care of themselves. Case managers verify that patients are scheduled for clinic appointments and have referrals for services needed.
* Fairview Southdale Hospital social workers will work with FPA nurse case managers and identify avoidable reasons that might return patients to the hospital. FPA will share the discharge plan information with the patients’ clinic providers.
* Fairview Southdale hospitalist physicians (doctors who manage admitted patients) will urge patients to see their clinic providers within five days of discharge. The hospitalist will expedite a summary of the hospital care to the clinic to make sure the primary care doctor has knowledge of the patient’s medical plan.
* Fairview Southdale Hospital pharmacists will thoroughly review with patients their current and new medications.

For more about FPA and its mission to improve the health of communities, visit fpanetwork.org.
For more about UCare, visit ucare.org.

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