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

  2. 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

  3. 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

  4. 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




  8. Transitions Summit Nov 2012 Formation of TNT Governance Jan 2013 Established Interdepartmental Feb 2013 - present Work Groups 2013 Goal: Region-wide,ALLdepartments within KPCO are “on-the-line” to reduce the 30-day hospital readmission rate. Transitions Network Team (TNT) Governance

  9. The Transition Bundle

  10. 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?”

  11. 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

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

  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 : LACERisk of Readmission Scoring Tool(1) (1) Walvaren et al. (CMAJ (2010) 182(6) : 551-557

  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. Low Risk 5.7% Moderate Risk 15.4% Baseline Readmission Rates by LACE Score High Risk 21.5% Very High Risk 32.5%

  16. Care Pathways Interventions According to Risk

  17. KPCO Adult Medicine Risk PoolLow Moderate High Care Pathways According to Risk of Readmission

  18. Transitions Care Coordinator (TCC) 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 • Telephonic transitional care coordination within 72 hours of discharge • “Owns” the patient for first 72 hours Care Coordination

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

  20. Medication Reconciliation

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

  22. fdsdsfdfdfdpppppffpf fdsdfdsfdssfdsfdsfdfdfd Medication Management and Discrepancy Reconciliation

  23. 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

  24. PACTHome 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." ~AlideChase 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. 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 PACTThe Secret Sauce

  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 PACT Teaching People How to Swim

  31. Readmission Review and Defect Analysis Negative Feedback Loop

  32. Most of the readmissions reviewed were: • Medicare members • The 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

  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


  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?