Readmission Reduction Strategies for Kaiser Permanente

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Readmission Reduction Strategies for Kaiser Permanente




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Presentations text content in Readmission Reduction Strategies for Kaiser Permanente

Slide1

Readmission Reduction Strategies for Kaiser Permanente Colorado Region

The Transition Bundle and PACT

Slide2

Presenters

Shelley Cooper, MBA, PMP

Senior

Manager Implementation Support

Jodi Smith, MSN, ANP-BC, ND

PACT

Program Lead

We

have no conflicts of interest to report

Slide3

Kaiser Permanente Colorado

Colorado’s oldest and largest group health care

540,000 members with 85,500 Medicare members

26 medical offices

6,000 Health Plan staff and Permanente Medical Group physicians

Recognized by NCQA as the top-ranked private health plan in Colorado and No. 13 in the entire nation for 2013-2014

Slide4

Kaiser Permanente Colorado

KP Colorado does

NOT

own its own hospitals

We contract with 5 area hospitals

New CMS regulations created a

ripe environment

to work on

readmission reduction with our hospital partners

Slide5

OUR READMISSION RATE WAS HIGHER THAN WE THOUGHT

The Problem...

Slide6

OUR READMISSION REDUCTION STRATEGIES WERE “

ONE-SIZE-FITS-ALL”

The Gap...

Slide7

DEVELOP READMISSION REDUCTION STRATEGIES THAT ARE TAILORED ACCORDING TO A MEMBERS RISK OF READMISSION

The Solution(s)...

Slide8

Transitions Summit

Nov 2012

Formation

of TNT

Governance

Jan 2013 Established Interdepartmental Feb 2013 - present

Work Groups

2013 Goal

:

R

egion-wide,

ALL

departments within KPCO

are “on-the-line” to

reduce the 30-day hospital readmission rate.

Transitions Network Team (TNT) Governance

Slide9

The Transition Bundle

Slide10

“Will my doctor know what happened to me in the hospital?” and

“Who should I call if I have a question about my hospitalization?”

Same Day Discharge Summary and Transition Phone Number

Slide11

Hospitalists,

PCPs and Specialists collaborated to create a simple, electronic DC Summary completed the day the patient leaves the hospital.

The standardized discharge summary has been implemented at our core contract hospitals,

representing 90% of total patient discharges

.

A “special”

phone number

was added to the DC

instructions for

patients to use

between discharge and outpatient follow up

Calls are answered by a live person 24/7

Standardized Same Day Discharge Summary

Slide12

Know Your Population and Where to Focus Your Efforts / Resources

Risk Stratification

Slide13

The

“LACE” model was developed in Ottawa as a tool to predict

30-day readmission

/ death rates

.

48 variables were evaluated, including living situation, age, functional limitations, medications, comorbidities, season, and

others.

Four variables were found to be the most powerful predictors of 30-day risk of readmission/death.

Risk Stratification : LACE

Risk of Readmission Scoring Tool

(1)

(1)

Walvaren

et al. (CMAJ (2010)

182

(6) : 551-557

Slide14

The

Canadian delivery systems

is,

in many

respects,

similar to the KP system

It has been validated against 1,000,000

Ottawa

patients

It has been validated against our own data retrospectively for 2009

LACE continued…

Slide15

LACE Score

30-Day Readmission Rate

1

0.0 %

2

0.0 %

3

9.1 %

4

5.9 %

5

6.3 %

6

5.7 %

7

8.7 %

8

8.9 %

9

24.8 %

10

17.1 %

11

15.7 %

12

23.8 %

13

22.0 %

14

32.0 %

15

26.1

%

16

31.8 %1733.3 %

Baseline Readmission Rates by LACE Score

Low Risk 5.7%

Moderate Risk 15.4%

High Risk 21.5%

Very High Risk 32.5%

Slide16

Interventions According to Risk

Care Pathways

Slide17

KPCO Adult Medicine Risk Pool

Low Moderate High

Care Pathways According to Risk of Readmission

Slide18

Transitions Care Coordinator (TCC)

Telephonic transitional care coordination within 72 hours of discharge

“Owns” the patient for first 72 hours

RN Care Coordinator (RNCC)

Embedded in the primary care clinics

Provides longitudinal, telephonic disease management and care coordination

Collaborates with PACT team for NCQA QI7

Care Coordination

Slide19

“I understand my medications, how to take them and why I need them.”

Medication Reconciliation

Slide20

Medication Reconciliation

Slide21

MEDICATION DISCREPANCY EXAMPLES

:

Patient taking double dose of B-blocker. DC instructions state, “

Metoprolol

25 mg, take 2 tabs twice daily”.

Pt

had 50 mg tabs at home and was taking "2 tabs“ as stated in the DC summary, therefore, taking

Metoprolol

100 mg twice daily (200 mg total). Pulse was 46 at PACT visit, BP 96/48.

DC instructions stated

STOP

Amlodipine and to

START

Metoprolol

. At PACT visit, wife was giving patient both medications.

Slide22

Medication Management and Discrepancy Reconciliation

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Slide23

Primary Care

Successfully reduced the average number of duplicate medications per 100 office visit encounters from 14% in 2010 to 8% as of the end of September 2013

Hospital Medicine

Med rec done on admission and discharge

PACT

During

the PACT visit, discrepancies are resolved and reconciled in real-time with the

pt

Pharmacy

Transition pharmacist reviews meds for 100% of patients discharged from SNF to home

Care Coordination

Telephonic med rec on hospital and ED discharges to home

Regional Medication Reconciliation Strategies

Slide24

PACTHome Visits

Slide25

"

What the organizations … share in common is this clear-eyed view that the status quo is not sustainable and that new models to simultaneously improve health, improve health care, and reduce per-capita costs aren’t just needed, they’re needed urgently."

~

Alide

Chase

A NEW MODEL

Slide26

‘POST-ACUTE CARE TRANSITIONS’

By coupling a robust readmission prediction tool (LACE) with strategically-designed post-discharge home visits (PACT), KPCO is able to target high intensity interventions specifically to patients who are at high risk of readmission.

A NEW

MODEL…..

PACT

Slide27

- A one-time home visit within 72 hours of hospital discharge

- To targeted, high-risk membersConducted by nurse practitioners INTERNAL to KPCO

Who collaborate and communicate across our care delivery system regarding each specific patient care plan and needs

PACT

Slide28

PACTThe Secret Sauce

Taking

care of uncertainty and leveraging competencies – medical care and community care – to create a supportive wrap-around system for the most vulnerable and complex patients

.

Stagger

points of care over time, not overwhelming patient with lots of care up

frontRight message in the right place at the right

time

Not the same as Home Health

Care

Slide29

In-person home visits by internal providers offers:

Objective empirical assessment of the patient’s needs in his/her home environment which is then communicated to all down-stream providers.

On-site, real-time medication reconciliation

,

Referral to appropriate follow up and supportive care

An exceptional level of ownership

Nurse Practitioners

May titrate/modify medications

May assess and treat post-hospitalization complications or treatment failures

May refer patients as necessary to additional services not considered at the time of

discharge

PACT Keys for Success

Slide30

BRIDGE OVER TROUBLED WATERS

PACT

Teaching People How to Swim

Slide31

Negative Feedback Loop

Readmission Review and Defect Analysis

Slide32

Most of the readmissions reviewed were:

Medicare membersThe likelihood that a defect will be identified increases:As the number of medications increase

The majority of readmissions are for reasons related to the index stay

Regardless of whether or not the readmission was related to the index stay,

approx

40% of cases reviewed had a defect identified

“Deterioration of Condition”, “Medication Issues” and “End of Life Issues” accounts for more than half of identified readmission defect issues

Defect Analysis Summary

Slide33

TNT Governance GroupPPSContinuing CarePrimary Care

Hospital MedicineWorld Congress???Thanks to …

Slide34

Risk stratify your populationTarget / tailor interventions according to riskDevelop dashboards to monitor progress

Engage stakeholdersOverly communicateContinue to persevere with your plan, no matter how difficult it is to change current practicesKeep the patient at the center of all you do

In conclusion

Slide35

Thank you: Questions?

Slide36

KPCO Post-Acute Discrepancies

Medication

Discrepancy Summary

Total PACT

Patients

449

Total Medication Discrepancies

933

Average Number of Med Discrepancies/patient

2.1

Slide37

PACT

POST-ACUTE CARE TRANSITIONS

Slide38

“What had tended to be seen as just an evitable consequence of people being sick is now increasingly seen as often being the consequence of not having done as good a job as we could have.”

Good Enough?

Slide39

Slide40


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