Excellent Transitions: Reducing Readmissions Lana McKinney RN, Continuity of Care Service Director...
-
Upload
gwen-parsons -
Category
Documents
-
view
212 -
download
0
Transcript of Excellent Transitions: Reducing Readmissions Lana McKinney RN, Continuity of Care Service Director...
Excellent Transitions: Reducing Readmissions
Lana McKinney RN, Continuity of Care Service DirectorMark Taylor MD, Hospital-Based ServicesKaiser Permanente San Rafael
January 2014
2 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Priority Areas of Focus Desired Outcome
The Quality Leader Management of those at greatest risk
Transitional Care Pharmacist
Follow-up appointments
Root causes of readmission
Post-discharge phone calls
Palliative Care
30-day readmission rate of 8% or less
Excellent Transitions: Reducing Readmissions
3 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
PCR Observed - All Ages30-Day Readmission Rate Control Chart
KP San Rafael
Source: KP Insight Report Library
4 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
PCR Observed/Expected Readmissions - All AgesTwelve Month Facility Comparison for Index Discharges ending in FEB2014
KP Northern California
KP San Rafael
Source: KP Insight Report Library
5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Management of Those at Greatest Risk
Excellent Transitions: Reducing Readmissions
In San Rafael, a Nurse Patient Care Coordinator (PCC) is teamed with a Hospitalist and supports the same caseload of patients. Triad rounds with the bedside nurse occur daily.
Patients with “Transitions Concerns” are identified promptly by the PCC and flagged in HealthConnect.
The PCC keeps the patient and family informed about the length of the hospital stay and facilitates post-discharge needs.
6 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Transitional Care Pharmacist (TCP)
Excellent Transitions: Reducing Readmissions
Transitional Care Pharmacists perform comprehensive medication reconciliation and provide bedside consults for nearly 2/3 of patients discharged to home.
TCPs maintain close relationships with the Hospitalist/PCC teams and work to resolve issues.
The TCP position is staffed 7 days/week, including holidays.
Follow-up phone calls are made for those with complex medication management and those that were unable to be seen at the bedside prior to discharge.
7 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
8 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Follow-up Appointments
Excellent Transitions: Reducing Readmissions
In San Rafael, 86% of patients discharged home are scheduled with an office visit or TAV that’s within 7 days of their discharge.
The vast majority of appointments are made by unit assistants prior to the patient’s discharge.
95% of discharge summaries are completed by the physician within 24 hours of discharge and routed in HealthConnect to primary care and other specialty providers.
9 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Did doctors, nurses or other hospital staff talk with you about whether
you would have the help you needed when you left the hospital?
Did you get information in writing about what symptoms or health problems to look out for after you left the
hospital?
Source: Service Quality Research Website
10 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Root Causes of Readmission
Excellent Transitions: Reducing Readmissions
Case studies and readmission data are reviewed by the local Resource Management Operations Group regularly.
The San Rafael Transitions Workgroup meets monthly and reviews detail readmission data, analyzes workflows, and proposes small tests of change.
Northern California Collaborative Calls provide analysis, industry trends and research, and sharing of solutions across medical centers.
A real-time discussion of cases with the discharging physician and current attending physician is facilitated by Dr. Taylor ad hoc, to gain further insights.
11 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Follow-up Phone Calls and Secure Messaging
Excellent Transitions: Reducing Readmissions
The discharging hospitalist stratifies patients as Low, Medium, or High Risk, and routes any specific concerns to the Transitions RN group.
A Transition RN makes a follow-up phone call and/or sends a secure message to check a patient’s progress within 72 hours of discharge. The RN triages to other clinicians as needed.
The Transitions Nurse also ensures appropriate referrals have been completed, DME has been delivered, and that the patient is aware of any follow-up appointments and labs.
12 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
13 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
14 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 19, 2023
Palliative Care
Excellent Transitions: Reducing Readmissions
90% of San Rafael Hospitalists are Board-certified in Palliative Care.
A local inpatient Palliative Care team includes a Clinical Nurse Specialist, an RN with hospice background, a Chaplain, and an LCSW. All are trained Respecting Choices POLST facilitators.
22 Palliative Care Nurse Champions on the bed units serve as resources for co-workers and are actively involved in KP’s Palliative Care initiatives. These Nurse Champions completed an all day training plus 4 one-hour modules; curriculum was presented by the Inpatient Palliative Care team and hospitalists.
Next Phase
Hospital to SNF setting
▪ Improved Hand-offs▪ Leverage HealthConnect▪ Root Cause Analysis▪ Medication Reconciliation
Questions?