When “Integrated” Care Doesn’t Show Up: How One Medicare Patient Fell Through a Health System’s Cracks

My mom is sick. I’m not asking for sympathy. She has a chronic illness and she’s been sick a long time. That’s her story to tell.

Mine is about what happens when a person with a chronic disease is a part of a large “integrated” health system and the integration never shows up.

She lives in a rural county within driving distance of a metro area. My uncle brought her for a f/u with her specialist, who sent her to the ER, about an hour from home thanks to construction. She was admitted for two nights.

She still works. She still lives on her own. She’s mentally sharp. Every current problem traces back to one disease.

I was on the road for back-to-back conferences with my husband, a physician. In between, we flew in to help. She was discharged three hours before our first flight. I asked the basics: meds? home health? follow-up with primary care? She said no to all three — and yes, she was surprised to be discharged on the same day as a procedure. I figured I’d piece it together after these two flights and some caffeine.

At dawn I started dialing. Her primary care clinic hadn’t been told she was hospitalized, we scheduled a next-day appointment. The specialist, she said, would call later that week about meds. Two weeks earlier, imaging had flagged the need for yet another specialty consult. No one called. No one coordinated.

We spent that day stocking the right food, picking up mobility aids, arranging follow-ups. She’s on traditional Medicare with a Medigap plan. Home health is covered. No one ordered it.

We left her at 10 p.m. She was upbeat.

By morning she was dizzy and short of breath. My husband examined her. We skipped primary care and drove to the ER. Five hours and some doctor-to-doctor coaxing later, she was readmitted — this time to a different hospital in the same system, another long drive away. We added our names to every release form we could find. Two front desk staffers weren’t sure what HIPAA was. That’s another story.

The next day they transferred her again so she could finally get the care that had been ordered.

The quality of the clinicians isn’t the story. Coordination is. My mom was discharged without meds, without a primary care follow-up, without home health. Specialists didn’t call. Within 48 hours she bounced back to the ER.

This isn’t a one-family fluke. Medicare literally penalizes hospitals with excess readmissions to push better communication and coordination. The 15-day readmission for this hospital is 6.42%, consistent with the statewide rate.

If my husband and I hadn’t rerouted our week to quarterback her care, what then? Most families don’t have a physician on speed dial or a daughter who works in healthcare. If an “integrated” system can’t integrate care for a patient whose doctors all share the same logo, how exactly will we coordinate it across different settings, payers and towns?

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