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Readmission Reduction Strategies for Kaiser Permanente Colorado Region The Transition Bundle and PACT.

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Presentation on theme: "Readmission Reduction Strategies for Kaiser Permanente Colorado Region The Transition Bundle and PACT."— Presentation transcript:

1 Readmission Reduction Strategies for Kaiser Permanente Colorado Region The Transition Bundle and PACT

2 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

3 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

4 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

5 OUR READMISSION RATE WAS HIGHER THAN WE THOUGHT The Problem...

6 OUR READMISSION REDUCTION STRATEGIES WERE “ ONE-SIZE-FITS-ALL ” The Gap...

7 DEVELOP READMISSION REDUCTION STRATEGIES THAT ARE TAILORED ACCORDING TO A MEMBERS RISK OF READMISSION The Solution(s)...

8 Transitions Summit Nov 2012 Formation of TNT Governance Jan 2013 Established Interdepartmental Feb present Work Groups 2013 Goal: ALL departments within KPCO are “on-the-line” to reduce the 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

9 Goal: Reduce Readmissions Risk Stratification Care Pathways Medication Reconciliation Standardized Same Day Discharge Summary Special Transition Phone Number Readmission Review and Feedback System The Transition Bundle

10 “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

11 Hospitalists, PCPs and Specialists collaborated to create a simple, electronic DC Summary completed the day the patient leaves the hospital. 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. 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 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 Calls are answered by a live person 24/7 Standardized Same Day Discharge Summary

12 Know Your Population and Where to Focus Your Efforts / Resources Risk Stratification

13 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) :

14 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…

15 LACE Score30-Day Readmission Rate 10.0 % % 45.9 % 56.3 % 65.7 % 78.7 % 88.9 % % % % % % % % % % Baseline Readmission Rates by LACE Score Low Risk 5.7% Moderate Risk 15.4% High Risk 21.5% Very High Risk 32.5%

16 Interventions According to Risk Care Pathways

17 -Transition call from TCC team within 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 KPCO Adult Medicine Risk Pool Low Moderate High Care Pathways According to Risk of Readmission

18 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

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

20

21 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.

22 Medication Management and Discrepancy Reconciliation f d s d f d sf d ss f d sf d sf d f d f d f d s d sf d f d f d p p p p p ff p f

23 o 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 o Hospital Medicine o Med rec done on admission and discharge o PACT o During the PACT visit, discrepancies are resolved and reconciled in real-time with the pt o Pharmacy o Transition pharmacist reviews meds for 100% of patients discharged from SNF to home o Care Coordination o Telephonic med rec on hospital and ED discharges to home Regional Medication Reconciliation Strategies

24 PACT Home Visits

25 "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

26 ‘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

27 - 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

28 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. - 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

29 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

30 BRIDGE OVER TROUBLED WATERS Upstream Downstrea m PACT Teaching People How to Swim

31 Negative Feedback Loop Readmission Review and Defect Analysis

32 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 stay o 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

33  TNT Governance Group  PPS  Continuing Care  Primary Care  Hospital Medicine  World Congress  ??? Thanks to …

34  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

35 Thank you: Questions?

36 KPCO Post-Acute Discrepancies Medication Discrepancy Summary Total PACT Patients449 Total Medication Discrepancies933 Average Number of Med Discrepancies/patient 2.1

37 PACT POST-ACUTE CARE TRANSITIONS

38 “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?


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