InnovaCare Health initiative featured in APG Case Studies in Excellence - InnovaCare Health
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InnovaCare Health initiative featured in APG Case Studies in Excellence

As featured in the 2019 Case Studies in Excellence from America’s Physician Groups.
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A ‘Golden’ Hospital Unit Improves Transitions of Care



The complexity of hospital admissions in chronic disease impacts health plans and the provider community. Over the years, unique interventions have been implemented to maximize outcomes and improve patient experience. Historically, inpatient management teams (hospitalists and case management) have had the most impact on the cost of inpatient care. But as inpatient management programs have evolved, other issues have impacted the alignment between health plans, provider groups, and hospitals.

At InnovaCare, we have a health plan (MMM Healthcare) with a large MSO (MSO of Puerto Rico) and a strong relationship with the provider community. We looked at improving transitions of care for patients in a way that benefited each of our stakeholders. This unique project impacted our Medicare Advantage (MA) membership.


Many clinical and quality outcomes are negatively impacted by ineffective transitions of care (TOC) during hospitalizations. Ineffective transitions can result in lower quality of care, financial drain, and potential compliance liability to stakeholders. Research has also shown that they can lead to higher admissions and readmissions, higher medical costs, lower member satisfaction, and increased disenrollment.

Root causes of ineffective transitions include poor communication and ineffective patient education. Examples include patients and caregivers receiving:

  • Unclear instructions concerning follow-up care
  • Conflicting recommendations of treatment
  • New medication schedules

It became clear to us that communication among discharge planners, hospitalists, and others interacting with inpatients was not as effective or coordinated as it could be. We needed a mutually agreeable strategy, where the three stakeholders (health plan, providers, and hospitals) benefited from a program that improved quality, financial efficiency, and member satisfaction and retention.

The solution: Create a dedicated hospital unit controlled by our key stakeholders. We used our health plan’s leverage to lease a hospital floor—which allowed our MSO to then optimize levels of care and coordinate all aspects of the admission for patients on that floor. The goal was to achieve better alignment among all groups, and most importantly, better outcomes.

The unit was initially a challenge to all stakeholders:

  • For the health plan: Would the medical groups provide enough redirected admissions to keep the prepaid floors busy year-round? Would members accept redirected admissions? How would it impact member retention?
  • For the medical groups: How would the other health plans receive this intervention? Could the IPAs redirect enough patients to this health plan-exclusive unit to impact their full-risk contracts to create savings—while improving overall quality of care and service?



MMM Healthcare leased entire hospital floors at three tertiary hospitals. We called these dedicated units “Unidad Dorada” (Golden Unit). The key to success was the alignment by the IPAs and medical groups to use these MMM-exclusive floors—and redirect potential MMM admissions from surrounding hospitals to our exclusive floors.


The intervention began with our contracted hospitalists seeing the patient in the emergency room after the patient was triaged by the ER. MSO-specific clinical protocols had an immediate impact. Enhanced multidisciplinary communication and active clinician participation positively changed cultural dynamics on the hospital floor. Thanks to standardized practices, the Unidad Dorada (UD) multidisciplinary team produced health and psychosocial assessments, care plans, and discharge plans in less than 48 hours of admission.

Admission to UD for each patient includes:

  • A UD welcome kit
  • Proprietary web portal access
  • 24/7 call center support
  • Bedside medication reconciliation and distribution upon discharge
  • Coordination of follow-up PCP visits
  • Follow-up phone calls
  • Home visit programs
  • Transportation

Patients also receive access to other MMM and MSO services, such as our Vita Care chronic care clinics; mental health, case management, and disease management programs; and follow-up visits.


The program began in 2016 but had to weather through the hurricanes of 2017. The results have been positive and continue to be very promising. We have broken down the results into three areas:

  1. Utilization of services

Our results (Table 1) include our Medicare Advantage membership between 2016 and 2018 at UD-participating hospitals:

  • Admits per thousand dropped from 184 to 175.
  • Our 30-day readmission rates fell 18%.
  • Average length of stay fell by 12%.
  • Redirected admissions to the UD-preferred hospitals increased regional market share for those hospitals by 30%.
  1. Health plan and member engagement

Patients and caregivers were significantly satisfied with services and quality of care (Table 2). Patient satisfaction was 99%, and overall membership retention increased to 98.7% among members who used the program.

The most improved areas for the health plan were medication adherence and reconciliation on the discharged UD patients, as well as increased PCP follow-up appointments after UD discharge. Medication adherence performance improved our Star rating from 4 to 5.

  1. Financial impact

Using partner hospitals that allowed us to coordinate medical care and manage transition of care issues resulted in significant financial improvements. The measurement years 2016 to 2018 showed improvement in regions where we had a UD hospital using most utilization metrics.

More importantly, in one of the regions, the IPAs redirected more than 35% (38% in 2019) of all their admissions to UD. This resulted in a 22% reduction in inpatient costs and a 10% improvement in overall savings between 2016 and 2018.


Table 1: Utilization Management
UM of Services 2016 2018 % Change
Admits/K 184 175 -4.9%
Length of Stay 5.8 5.1 -12.1%
30-day Readmit % 12.3% 10.1% -17.9%
Redirects to UD* 23% 30% 30.4%

The table shows utilization management improvements after two years of Unidad Dorada.

* Indicates regional market share for hospitals participating in the UD program.


Table 2: Member Engagement
Metric 2018 2019 % Change
Member Retention 93.7% 98.7% 5.3%
Bedside Rx (prior to DH) 17% 65% 282.4%
Post-DH Appointment 10% 62% 520%
Member Satisfaction 99% 99% No change

Unidad Dorada improved member engagement in multiple areas. Although UD began in 2016, these initiatives were not measured until 2018. (DH = discharge home)



MSO of Puerto Rico, LLC (MSO), is a full-service health management organization in Puerto Rico. We focus on efficiency and high-quality delivery of care through innovation and tools that allow excellent clinical, administrative, and financial results. We manage 21 independent practice associations (IPAs) with a network of more than 5,000 PCPs and specialists impacting 255,000 Medicare Advantage members, and 88 IPAs impacting 275,000 Medicaid patients. MSO also owns the largest Medicare Advantage IPA on the island: Castellana Physician Services, LLC, with 80,064 Medicare Advantage members and a network of 800 PCPs and specialists.