1. Excellent Transitions: Reducing Readmissions Lana McKinney RN, Continuity of Care Service Director Mark Taylor MD, Hospital-Based Services Kaiser Permanente San Rafael January 2014

2. 2| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 PriorityAreas 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. 3| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 PCR Observed - All Ages 30-Day Readmission Rate Control Chart KP San Rafael Source: KP Insight Report Library

4. 4| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 PCR Observed/Expected Readmissions - All Ages Twelve Month Facility Comparison for Index Discharges ending in FEB2014 KP Northern California KP San Rafael Source: KP Insight Report Library

5. 5| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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. 6| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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. 7| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015

8. 8| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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. 9| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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. 10| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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. 11| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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. 12| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015

13. 13| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015

14. 14| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 2, 2015 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.

15. Next Phase

16. Hospital to SNF setting ▪ Improved Hand-offs ▪ Leverage HealthConnect ▪ Root Cause Analysis ▪ Medication Reconciliation

17. Questions?