Download Readmission Reduction Strategies for

Readmission
Reduction Strategies
for Kaiser Permanente
Colorado Region
The Transition Bundle and PACT
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
Presenters
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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
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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
Kaiser Permanente Colorado
The Problem...
OUR READMISSION RATE WAS HIGHER THAN WE THOUGHT
The Gap...
OUR READMISSION REDUCTION STRATEGIES WERE
“ONE-SIZE-FITS-ALL”
The Solution(s)...
DEVELOP READMISSION REDUCTION STRATEGIES THAT ARE
TAILORED ACCORDING TO A MEMBERS RISK OF READMISSION
Transitions Network Team (TNT) Governance
Transitions Summit
Nov 2012
Formation of TNT Governance
Jan 2013
Established Interdepartmental
Work Groups
Feb 2013 - present
2013 Goal: Region-wide, ALL departments within KPCO
are “on-the-line” to reduce the
30-day hospital readmission rate.
Risk
Stratification
Readmission
Review and
Feedback
System
Care
Pathways
Goal:
Reduce
Readmissions
Special
Transition
Phone
Number
Medication
Reconciliation
Standardized
Same Day
Discharge
Summary
The Transition Bundle
Same Day Discharge
Summary and Transition
Phone Number
“Will my doctor know what happened to me
in the hospital?”
and
“Who should I call if I have a question about
my hospitalization?”
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Hospitalists, PCPs and Specialists collaborated to
create a simple, electronic DC Summary completed
the day the patient leaves the hospital.
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The standardized discharge summary has been
implemented at our core contract hospitals,
representing 90% of total patient discharges.
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A “special” phone number was added to the DC
instructions for patients to use between discharge
and outpatient follow up
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Calls are answered by a live person 24/7
Standardized Same Day
Discharge Summary
Risk Stratification
Know Your Population and Where
to Focus Your Efforts / Resources
Risk Stratification : LACE
Risk of Readmission Scoring Tool(1)
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.
(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…
Baseline Readmission Rates
by LACE Score
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 %
Low Risk
5.7%
Moderate Risk
15.4%
High Risk
21.5%
Very High Risk
32.5%
Care Pathways
Interventions According to Risk
KPCO Adult Medicine Risk Pool
Low
-Transition call from TCC team
within 48-72 hours
Moderate
High
Same as low risk, except:
Same as low and medium risk,
except:
- Office visit with PCP within 7
days
- PACT home visit within 72 hrs
- Medication Reconciliation
- Appoint booking / confirmation
- Phone visit with PCP within 7
days
- PCP appointment per PACT
APN recommendation
- Override to higher level of care
or forward to RNCC if necessary
Care Pathways According to Risk of Readmission
Transitions Care Coordinator
(TCC)
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Telephonic transitional
care coordination within
72 hours of discharge
“Owns” the patient for
first 72 hours
RN Care Coordinator
(RNCC)
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Embedded in the
primary care clinics
Provides longitudinal,
telephonic disease
management and care
coordination
Collaborates with PACT
team for NCQA QI7
Care Coordination
Medication
Reconciliation
“I understand my medications, how
to take them and why I need them.”
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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Regional Medication Reconciliation Strategies
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Primary Care
o 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
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Hospital Medicine
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Med rec done on admission and discharge
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PACT
o During the PACT visit, discrepancies are resolved and reconciled in
real-time with the pt
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Pharmacy
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Transition pharmacist reviews meds for 100% of patients discharged from
SNF to home
Care Coordination
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Telephonic med rec on hospital and ED discharges to home
PACT
Home 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
PACT
- A one-time home visit within 72 hours of hospital discharge
- To targeted, high-risk members
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Conducted by nurse practitioners INTERNAL to KPCO
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Who collaborate and communicate across our care delivery system
regarding each specific patient care plan and needs
PACT
The 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.
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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
PACT Keys for Success
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 downstream 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
BRIDGE OVER TROUBLED WATERS
PACT
Teaching People How to Swim
Upstream
Downstream
Readmission Review
and Defect Analysis
Negative Feedback Loop
Defect Analysis Summary
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Most of the readmissions reviewed were:
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The likelihood that a defect will be identified increases:
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As the number of medications increase
The majority of readmissions are for reasons related to the
index stay
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Medicare members
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
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TNT Governance Group
PPS
Continuing Care
Primary Care
Hospital Medicine
World Congress
???
Thanks to …
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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
PACT
POST-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?