With special expertise in geriatric medicine, our clinicians deliver comprehensive onsite care to patients living at home or in assisted and independent living facilities across the state. Our proactive, prevention-oriented care is specifically designed to keep patients on an even keel and avoid crises – the key to reducing unnecessary 30-day readmissions.

We see our patients within 48 hours of discharge from the hospital, and follow-up often and in detail during the post-acute period. We also respond immediately to urgent care needs. The net effect of our unique strategy is dramatic reductions in readmissions, even for the most complex, high-needs patients who are most at risk for readmission.

Based on data direct from the Center for Medicare/Medicaid Services (CMS) and The Center for Medicare and Medicaid Innovation (CMMI), our practice has demonstrated the ability to reduce 30-day readmission rates by an amazing and unprecedented 60%!

Case Managers, Discharge Planners and Social Workers

You are in the unique position to determine a patient’s path for post-acute medical care. We also understand and support that you have dual responsibilities – to advocate first and foremost for your patients and ensure they achieve the best clinical outcomes possible, while also serving the best financial interests of your institution or organization. DMHC enables you to fulfill all those commitments, entirely without compromise.

Care coordination

Care coordination facilitates care progression and ensures that the inpatient stay is not extended unnecessarily. Case managers, discharge planners and social workers coordinate care with the physician, the hospital healthcare team and others to ensure that care is appropriate and progresses according to the medical treatment plan.

Discharge planning

Timely and appropriate discharge planning facilitates patient transition to the next level of care and helps avoid unnecessary extension of the length-of-stay. Unnecessarily prolonged LOS translates to higher costs and lower profitability for that episode of care, and even to payment denials for services already provided.

The DMHC mission supports Transition Teams on both fronts.

We seek to keep post-acute patients out of SNF/Rehab facilities, because patients discharged to those places are at high risk for unnecessary readmissions. Discharging patients instead to an ALF or private residence, where they can receive comprehensive onsite care from DMHC clinicians, offers BETTER clinical outcomes compared with a SNF, with a much lower likelihood of readmission within 30, 60 and 90 days.

Here’s why:

  • SNFs have a strong financial incentive to readmit patients to the hospital – a perverse incentive from the hospital’s perspective – because when the patient returns to the SNF, Medicare payments resume for another 21 days, and are much higher vs. what Medicaid pays for LTC.
  • ALFs have a powerful incentive to avoid readmissions, because patients who are admitted to the hospital and then discharged to the SNF/Rehab facility, often never return to the ALF.  Facility managers are typically rewarded based on the occupancy rates at their facility, and therefore have a strong incentive to reduce attrition.
  • By partnering with DMHC, ALFs can now offer comprehensive onsite care to their residents, including labs, imaging, skilled nursing, physical therapy, even IV therapy with PICC lines inserted – all performed onsite.
    • DMHC clinicians visit patients discharged to an ALF or private residence within 48 hours of d/c from the hospital, and conduct a thorough evaluation and medication reconciliation, to ensure patients promptly receive the care they need.
    • Throughout the post-acute period, DMHC clinicians see patients as often as necessary and provide care that is proactive and prevention oriented, instead of reactive and crisis-driven.
    • DMHC clinicians are board-certified and hand-picked by DMHC’s physician founders for their commitment to clinical excellence, and their special expertise in caring for high risk, high needs patients. Our capabilities in this field are nationally renowned.
    • Our clinicians coordinate any lab tests or imaging procedures required for optimal care.  Except for CT or MRI, all services are provided onsite. DMHC can even arrange for and supervise daily IV antibiotic infusions if the patient has a PICC line. 
    • The ONLY reason to refer a patient to a rehab hospital or SNF – and greatly increase the risk of a readmission within 30-days – is if the patient requires 24-hour nursing care.

Complete information about our services and the registration process, can be found in the FAQ section of this website. Patients may be registered online, via phone at 919-932-5700 or toll free 844-932-5700, or via email at newpatient@DoctorsMakingHousecalls.com