readmission reduction strategies for kaiser permanente colorado region the transition bundle and...
TRANSCRIPT
Readmission Reduction
Strategies for Kaiser Permanente
Colorado Region
The Transition Bundle and PACT
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
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
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
OUR READMISSION RATE WAS HIGHER THAN WE THOUGHT
The Problem...
OUR READMISSION REDUCTION STRATEGIES WERE
“ONE-SIZE-FITS-ALL”
The Gap...
DEVELOP READMISSION REDUCTION STRATEGIES THAT ARE TAILORED ACCORDING TO A MEMBERS RISK OF READMISSION
The Solution(s)...
Transitions Summit Nov 2012
Formation of TNT Governance Jan 2013
Established Interdepartmental Feb 2013 - present
Work Groups
2013 Goal: Region-wide, ALL departments within KPCO are “on-the-line” to reduce the 30-day hospital readmission rate.
Transitions Network Team (TNT) Governance
Goal:Reduce
Readmissions
Risk Stratificati
on
Care Pathways
Medication
Reconciliation
Standardized Same
Day Discharge Summary
Special Transition
Phone Number
Readmission Review
and Feedback System
The Transition Bundle
“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
• 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 24/7Standardized Same
Day Discharge Summary
Know Your Population and Where to Focus Your Efforts / Resources
Risk Stratification
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 : LACERisk of Readmission Scoring Tool(1)
(1) Walvaren et al. (CMAJ (2010) 182(6) : 551-557
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…
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 %
17 33.3 %
Base
lin
e R
ead
mis
sion
R
ate
s b
y L
AC
E S
core
Low Risk 5.7%
Moderate Risk 15.4%
High Risk 21.5%
Very High Risk 32.5%
Interventions According to Risk
Care Pathways
-Transition call from TCC team within 48-72 hours- Medication Reconciliation- Appoint booking / confirmation- Phone visit with PCP within 7 days- Override to higher level of care or forward to RNCC if necessary
Same as low risk, except:
- Office visit with PCP within 7 days
Same as low and medium risk, except:
- PACT home visit within 72 hrs- PCP appointment per PACT APN recommendation
KPCO Adult Medicine Risk Pool
Low Moderate High
Care Pathways According to Risk of Readmission
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
“I understand my medications, how to take them and why I need them.”
Medication Reconciliation
Medication Reconciliation
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.
Medication Management and Discrepancy Reconciliation
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o Primary Careo 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
o Hospital Medicineo Med rec done on admission and discharge
o PACTo During the PACT visit, discrepancies are resolved and
reconciled in real-time with the pt
o Pharmacyo Transition pharmacist reviews meds for 100% of patients
discharged from SNF to home
o Care Coordinationo Telephonic med rec on hospital and ED discharges to home
Regional Medication Reconciliation Strategies
PACTHome Visits
"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
‘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
- A one-time home visit within 72 hours of hospital discharge
- To targeted, high-risk members
- Conducted by nurse practitioners INTERNAL to KPCO
- Who collaborate and communicate across our care delivery system regarding each specific patient care plan and needs
PACT
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 front
- Right message in the right place at the right time- Not the same as Home Health Care
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
BRIDGE OVER TROUBLED WATERS
Upstream Downstrea
m
PACT Teaching People How to Swim
Negative Feedback Loop
Readmission Review and Defect Analysis
o Most of the readmissions reviewed were:o Medicare members
o The likelihood that a defect will be identified increases:o As the number of medications increase
o The majority of readmissions are for reasons related to the index stayo Regardless of whether or not the readmission was
related to the index stay, approx 40% of cases reviewed had a defect identified
o “Deterioration of Condition”, “Medication Issues” and “End of Life Issues” accounts for more than half of identified readmission defect issues
Defect Analysis Summary
TNT Governance Group PPS Continuing Care Primary Care Hospital Medicine World Congress ???
Thanks to …
Risk stratify your population Target / tailor interventions according to
risk Develop dashboards to monitor progress Engage stakeholders Overly communicate Continue to persevere with your plan, no
matter how difficult it is to change current practices
Keep the patient at the center of all you do
In conclusion
Thank you: Questions?
KPCO Post-Acute Discrepancies
Medication Discrepancy Summary
Total PACT Patients 449
Total Medication Discrepancies 933
Average Number of Med Discrepancies/patient
2.1
PACTPOST-ACUTE CARE TRANSITIONS
“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?