Misha Palecek, chief transformation officer at DaVita
Photo: Misha Palecek
DaVita is one of the largest kidney care providers in the world, with both in-center and home dialysis options. While DaVita isn't a traditional health system, the organization does operate inpatient dialysis services within hospitals through its DaVita Hospital Services division.
It also offers home-based healthcare systems like home dialysis and some primary care services through its DaVita Health Solutions programs.
THE CHALLENGE
DaVita has long recognized the complexity of treating patients with overlapping chronic conditions. Kidney disease rarely exists in isolation – it often coexists with heart failure, diabetes and/or hypertension, creating a variety of clinical needs that demand seamless coordination across specialties.
Historically, the healthcare industry has struggled to deliver truly integrated care. Fragmented communication, delayed data sharing and reactive interventions have often left patients vulnerable – especially during critical transitions like hospital discharge, said Misha Palecek, chief transformation officer at DaVita.
"The data underscores the urgency," he stated. "Nearly half of patients in the U.S. with late-stage chronic kidney disease and two-thirds of those with end-stage kidney disease also suffer from congestive heart failure. Among CHF patients, 40% are readmitted to the hospital within 90 days of discharge – a clear signal that traditional care models risk meeting the moment.
"One of the most persistent challenges can be a lack of timely notification when patients are admitted or discharged," he continued. "Without real-time visibility, care teams are often left out of the loop during the most vulnerable phase of recovery, unable to intervene or support patients navigating complex discharge instructions."
DaVita saw this gap not just as a challenge but as an opportunity to lead.
"Over the past several years, we've made strategic investments in technologies and partnerships that support the advancement of our vision for integrated, patient-centered care," Palecek noted. "One such investment is Linea, a platform focused on improving outcomes for patients with CHF through better care coordination and data-driven interventions.
"The vendor's platform enables real-time data sharing between nephrologists and cardiologists, supports timely interventions, and empowers providers to optimize treatment using Guideline-Directed Medical Therapy," he continued. "This is especially critical given that most eligible CHF patients are not on all recommended medications – and even fewer are on the right doses."
The vendor's system helps close that gap by facilitating frequent monitoring, lab reviews and dose adjustments that would otherwise be difficult to achieve through traditional specialist visits, he added.
"Linea is one example of how DaVita is leaning into innovation to help to transform care delivery," Palecek said. "By bridging the divide between chronic and episodic care, we not only have the potential to improve outcomes for patients with CHF and kidney disease, we're helping shape the future of integrated care.
"As the healthcare industry continues to evolve, DaVita remains committed to leading the way with systems that aim to empower and enable clinicians, deepen engagement with patients, and deliver better health every step of the way," he added.
PROPOSAL
Before implementation, Linea proposed a transformative approach to integrated care for high-risk CHF patients, Palecek explained.
"Its AI-powered platform aimed to identify hospitalizations in real time and maintain visibility throughout the critical 90-day post-discharge period," he said. "This early insight would allow care teams to begin coordination before patients left the hospital – supporting a seamless continuum of care post-discharge."
The proposed solution integrated four key components, he detailed:
- AI-powered hospital admission and discharge detection, enabling timely identification of patients who may be at risk.
- With a combination of AI and pharmacist insights, technology is able to generate medication plan recommendations within hours rather than days or weeks of discharge.
- AI-prompted patient reported vitals and symptom tracking that can alert care teams if vitals are out of range and/or if information is not reported.
- AI-enabled 24/7 virtual care services, offering patients continuous access to support and guidance.
MEETING THE CHALLENGE
DaVita implemented the platform with a clear goal: to make care more connected, timely and responsive – especially for patients with kidney disease who are at higher risk for cardiac events.
"The model was designed to work alongside clinicians, not around them," Palecek explained. "The platform works in conjunction with our existing clinical workflows, electronic health records and systems, connecting kidney care with cardiology, primary care and accountable care organization teams without disrupting our established operations.
"The results have been promising," he reported. "More than 70% of patients are engaged before discharge, and most connect with their care team within two days of a health event. This means that patients – especially complex CHF patients – are receiving the support they need to manage their treatment earlier.
"In the first 30 days post-hospitalization, patients receive over a dozen supportive calls and messages – compared to the national average, where 60% receive no follow-up at all," he continued. "This level of engagement has helped drive down 90-day readmission rates to under 25%, compared to the national average of 40%."
RESULTS
One of the most meaningful outcomes DaVita has seen is a shift from reactive to proactive care, and in tandem, a shift from reacting to a health event to proactively managing it alongside chronic illness.
"By leveraging technology that surfaces real-time insights, care teams are now able to engage patients earlier and more consistently, creating a more seamless and supportive experience," Palecek said.
"This proactive engagement has also unlocked broader system-level benefits," he continued. "Reducing avoidable hospital readmissions not only helps improve patient outcomes but also helps alleviate financial strain across the healthcare ecosystem. These avoided episodes allow for shared savings, which can be reinvested into preventive care and innovation."
ADVICE FOR OTHERS
Healthcare organizations considering AI-driven, integrated care technologies should approach implementation as a clinical transformation – not just a tech deployment, Palecek advised.
"These tools can be powerful enablers of better care coordination, earlier intervention and improved outcomes, but they require more than just plugging into your systems," he said. "Success depends on thoughtful integration into existing platforms, strong leadership alignment and a commitment to change management.
"One of the most important measures of success is physician engagement," he continued. "These technologies often introduce new ways of working – whether it's real-time alerts, virtual care coordination or remote monitoring. That can feel disruptive, especially in high-acuity environments like nephrology or cardiology."
Demonstrating early wins, like reduced readmissions or improved patient satisfaction, can build momentum and trust across the organization, he added.
"It's also essential to align technology adoption with the needs of the population being served," Palecek noted. "Integrated care platforms tend to deliver the greatest value for patients with complex, chronic conditions and frequent hospitalizations. If your population is relatively healthy or low-utilization, the impact may be less immediate.
"Define success metrics upfront – whether it's better transitions of care, improved medication adherence or faster follow-up – and track them rigorously," he added.
Finally, these technologies work best when embedded within a broader value-based, integrated care strategy, he said.
"They're not just tools for efficiency," he concluded. "They're enablers of a more proactive, patient-centered model. Organizations should think beyond implementation and consider how these platforms can support long-term goals around population health, access and sustainability. The real opportunity lies in using technology not just to fill gaps, but to improve how care is delivered altogether."
Follow Bill's health IT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.
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