Transcript Excellent Transitions: Reducing Readmissions

Excellent Transitions: Reducing
Readmissions
Lana McKinney RN, Continuity of Care Service Director
Mark Taylor MD, Hospital-Based Services
Kaiser Permanente San Rafael
January 2014
Excellent Transitions:
Reducing Readmissions
Priority
The Quality Leader
Areas of Focus
 Management of those at
greatest risk
 Transitional Care
Pharmacist
 Follow-up appointments
 Root causes of
readmission
 Post-discharge phone calls
 Palliative Care
2
July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Desired Outcome
30-day readmission rate of
8% or less
PCR Observed - All Ages
30-Day Readmission Rate Control Chart
KP San Rafael
Source: KP Insight Report Library
3 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
PCR Observed/Expected Readmissions - All Ages
Twelve Month Facility Comparison for Index Discharges ending in FEB2014
KP Northern California
KP San Rafael
Source: KP Insight Report Library
4 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Excellent Transitions: Reducing Readmissions
Management of Those at Greatest Risk
 In San Rafael, a Nurse Patient Care Coordinator (PCC) is teamed with a
Hospitalist and supports the same caseload of patients. Triad rounds with the
bedside nurse occur daily.
 Patients with “Transitions Concerns” are identified promptly by the PCC and
flagged in HealthConnect.
 The PCC keeps the patient and family informed about the length of the hospital
stay and facilitates post-discharge needs.
5 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Excellent Transitions: Reducing Readmissions
Transitional Care Pharmacist (TCP)
 Transitional Care Pharmacists perform comprehensive medication reconciliation
and provide bedside consults for nearly 2/3 of patients discharged to home.
 TCPs maintain close relationships with the Hospitalist/PCC teams and work to
resolve issues.
 The TCP position is staffed 7 days/week, including holidays.
 Follow-up phone calls are made for those with complex medication
management and those that were unable to be seen at the bedside prior to
discharge.
6 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
7 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Excellent Transitions: Reducing Readmissions
Follow-up Appointments
 In San Rafael, 86% of patients discharged home are scheduled with an office
visit or TAV that’s within 7 days of their discharge.
 The vast majority of appointments are made by unit assistants prior to the
patient’s discharge.
 95% of discharge summaries are completed by the physician within 24 hours of
discharge and routed in HealthConnect to primary care and other specialty
providers.
8 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Did doctors, nurses or
other hospital staff talk
with you about whether
you would have the
help you needed when
you left the hospital?
Did you get information
in writing about what
symptoms or health
problems to look out
for after you left the
hospital?
Source: Service Quality Research Website
9 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Excellent Transitions: Reducing Readmissions
Root Causes of Readmission
 Case studies and readmission data are reviewed by the local Resource
Management Operations Group regularly.
 The San Rafael Transitions Workgroup meets monthly and reviews detail
readmission data, analyzes workflows, and proposes small tests of change.
 Northern California Collaborative Calls provide analysis, industry trends and
research, and sharing of solutions across medical centers.
 A real-time discussion of cases with the discharging physician and current
attending physician is facilitated by Dr. Taylor ad hoc, to gain further insights.
10 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Excellent Transitions: Reducing Readmissions
Follow-up Phone Calls and Secure Messaging
 The discharging hospitalist stratifies patients as Low, Medium, or High Risk, and
routes any specific concerns to the Transitions RN group.
 A Transition RN makes a follow-up phone call and/or sends a secure message
to check a patient’s progress within 72 hours of discharge. The RN triages to
other clinicians as needed.
 The Transitions Nurse also ensures appropriate referrals have been completed,
DME has been delivered, and that the patient is aware of any follow-up
appointments and labs.
11 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
12 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
13 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Excellent Transitions: Reducing Readmissions
Palliative Care
 90% of San Rafael Hospitalists are Board-certified in Palliative Care.
 A local inpatient Palliative Care team includes a Clinical Nurse Specialist, an
RN with hospice background, a Chaplain, and an LCSW. All are trained
Respecting Choices POLST facilitators.
 22 Palliative Care Nurse Champions on the bed units serve as resources for coworkers and are actively involved in KP’s Palliative Care initiatives. These
Nurse Champions completed an all day training plus 4 one-hour modules;
curriculum was presented by the Inpatient Palliative Care team and hospitalists.
14 July 21, 2015
|
© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Next Phase
Hospital to SNF setting
▪ Improved Hand-offs
▪ Leverage HealthConnect
▪ Root Cause Analysis
▪ Medication Reconciliation
Questions?