Specifically, the vendor will sell hospitals a package of services designed to help them avoid payment reductions associated with excess hospital readmissions.  The services will be marketed to hospitals directly and through group purchasing organizations authorized to act as purchasing agents for hospitals.  Agreements to purchase the services will be in writing, signed by both the vendor and hospitals, and have a term of not less than one year.  The Agreement will also spell out all of the services that the vendor will provide to hospitals.  The vendor will charge hospitals standard fees at fair market value. In other words, agreements between the vendor and hospitals will meet the requirements of the personal services and management contracts safe harbor or exception under the federal anti-kickback statute.

Hospitals will be able to purchase services from the vendor on a patient-by-patient basis that they expect will help reduce preventable readmission rates.  Discharge planners/case managers will identify patients who may benefit from services offered by the vendor.  If patients elect to receive the services, discharge planners/case managers will enter their discharge plans into the vendor’s software system.

Participating patients will have access for a twelve-hour period each day to a patient liaison who will help them understand and follow their discharge plans.  For the remaining twelve-hour period each day then patient liaisons are unavailable, participating patients will be automatically transferred to a twenty-four-hour nurse hotline.  Patient liaisons, who are not necessarily clinicians, will contact participating patients within forty-eight hours of discharge to ensure that they understand and will follow discharge plans.

Thereafter, patient liaisons will contact participating patients daily or at intervals selected by contracting hospitals to administer questionnaires about participating patients’ health and compliance with discharge plans.Participating patients may also answer questionnaires on the internet or through telephone interactive voice response systems.  Patient liaisons will ask participating patients about medication compliance, remind them about refills, and add newly-prescribed medication to their electronic health records.  Patient liaisons may also assist participating patients with various tasks, such as scheduling follow-up appointments, reminding them about scheduled appointments or helping them obtain transportation at participating patients’ own cost, providing participating patients with unbranded educational materials intended for general audiences, and providing updates to participating patients’ caregivers and primary care providers.  Reports will be provided to hospitals regarding patients’ medication adherence, post-discharge physician appointment completion, readmission rates, demographics, readmitting hospitals, and secondary diagnoses.