Kaiser’s Transition Care Bundle: Six Steps to Reducing Readmissions

Even before the Affordable Care Act passed, preventable readmissions were on a lot of minds in the U.S. healthcare system. In 2009 the Centers for Medicare & Medicaid Services began publishing hospitals’ readmit rates on its Hospital Compare website, and the ACA, signed the next year, brought about a financial stick in the form of lost reimbursement as more incentive to trim them.

By that time leaders of Kaiser Permanente’s Northwest branch had already developed a transition care package aimed at achieving that end. That package proved effective enough in practice to be replicated across the healthcare giant’s sizable U.S. footprint.

“Our readmission rate was never super high like you might see in some systems, but you can always drive it down,” says Tami Hillstrom, director of Kaiser Northwest’s Regional Telephonic Medicine Center (RTMC), which helps patients transition among the various segments of their medical journeys. “We knew we wanted a lower readmission rate, and we saw where CMS was going with the reimbursement and penalties. It was a pretty compelling case to move forward.”

The transition care bundle, containing six elements, helped KP’s Northwest operation cut its all-cause rate from 14%–15% to 9½%–10%.

“It’s a challenging thing to do,” says Rahul Rastogi, MD, director of operations for continuing care services and medical director for the RTMC. “There are lots of issues at play from the time a patient shows up in the hospital through what happens to them there and when they leave and the following 30 days after. It’s a complex process. Every patient’s different, so they all need a very tailored approach.”

The Postdischarge Bundle

The transition bundle permits that. Briefly its components are:

• Risk stratification—Based on a number of criteria—things like level of illness, comorbidities, prior hospitalizations, age and social factors—patients are categorized as low-, medium- or high-risk for readmission at the time of their index admission. This determination helps guide their care during their stay.

• Standard discharge summary—Discharge summaries may lack important information primary care physicians need to help their patients avoid readmission. The goal of the standard discharge summary is to reliably convey key information for the patient and their PCP: medication changes, new equipment, test results, referrals, etc.

“Before our transition care work, that wasn’t standardized,” says Hillstrom. “There wasn’t clean communication back to the primary-care physician about what happened in the hospital and what areas the inpatient physician was worried about that should be followed up. Now that communication is very clean, so when the patient follows up with their physician, that physician knows exactly what tests to order or look for and what issues the inpatient physician was worried about. That communication link really improved a lot.”

• Medication reconciliation—Developing and maintaining accurate medication lists requires the coordination of all the doctors a patient sees across the care spectrum. As these can change with each visit, it’s easy for discrepancies to occur. This element entails both quantitative and qualitative reconciliation: making sure patients are taking the right amounts of the right drugs and understand potential adverse events and what to do if one happens.

• Postdischarge hotline—The first week is the toughest: A 2013 study found around a third of 30-day readmissions happen within seven days of discharge. Social issues often contribute. Providing a 24/7 number patients can call with questions or emergencies can help prevent problems worsening and forestall return visits. Callers are connected to an advice nurse and, if needed, a hospitalist.

• Postdischarge phone call—Follow-up calls help reduce readmission rates. Kaiser’s, made by nurses within 48–72 hours of discharge, are aimed at detecting warning signs (e.g., adverse reactions, social issues, compliance) that may precipitate a return.

“Patients are often medicated, stressed and fatigued after being in the hospital,” noted author Philip Tuso, MD, in a 2013 Permanente Journal article describing the bundle’s adoption in Southern California. “They may not remember any of the discharge instructions. The goal of the posthospital phone call is to provide reliable high-quality clinical phone support for our patients after discharge.”

• PCP visit within seven days—Thirty-day readmission rates are higher for those who don’t see primary-care docs after discharge—three times as high (31% vs. 10%) per one study. Getting patients back to their regular docs in a timely way is important.

It took some time and tinkering to figure out exactly what that bundle should contain. As far back as 2008 program architects were testing a simpler approach that used just a hospital pharmacist to reconcile medications and a nurse who called after discharge.

“The results of that told us it’s not one single entity or working in a silo that’s going to impact readmissions; it’s everyone working together across the continuum,” says Yvonne Rice, PharmD, clinical coordinator for transition pharmacy services and northwest regional business lead for transition care. “It’s really engaging everyone: the care coordinator, the social worker, the nurse, the physician.”

A key member of the team was a lay patient adviser whose mother had experienced some transition problems. He lent the patient perspective to the process and provides input to program leaders to this day.
“Adding a patient was possibly our most important intervention,” adds Rice. “That was really key to keeping us focused on the patient care experience.”

Once the bundle was developed, it was expanded not only to the hospitals in Kaiser’s Northwest region but the non-Kaiser hospitals they work with as well. Kaiser’s other medical groups adopted it too, sending representatives to Portland to work with the designers and learn its guiding principles.

Adding EMS

A newer component to Kaiser Northwest’s program began last year: using an EMS partner—in this case Hillsboro-based Metro West—to visit the recently discharged at home. It’s an additional line of defense against that high rate of first-seven-days rehospitalization.

“We did some testing two years ago with this in terms of following discharged patients home and learned there would be value in it,” says Rastogi. “Where we’re at now is actually standardizing the transition visit and processes so the paramedics are fully connected: When they arrive at a home and find an emergency or a situation they need to address, to whom do they escalate it and how do they get that connection? We’re optimistic this will be something that will help reduce readmissions.”

These mobile health partners, as they’re known in the program, are used with high-risk patients and any others about whom physicians have extra concerns. These can include special needs in the home setting; EMS providers are well aware how the home environment can impact health behaviors. They visit high-risk patients within 24–48 hours of their return home.

“There can be a lot of unanticipated circumstances when these patients land back in their homes,” says Rastogi. “It’s a big black box of an unknown. Many don’t have providers coming in; they may not have a skilled nursing need to require home health to come out. And when home health does come, they’re usually sent with a specific purpose and focus, so they may miss some things. So we looked at this as an opportunity to fill in some gaps for patients who didn’t necessarily have someone coming into their home.”

Laying actual eyes on the home environment is the optimal way to detect things like fall hazards and medication compliance issues (program pharmacists can also dispatch the medics for medication reviews). It can also provide insight into factors like diet and transportation that can affect access to and the effectiveness of healthcare.

“When we looked at our readmission factors, the psychosocial reasons were always near the top,” says Hillstrom. “Having the paramedics able to lay eyes on that home environment and go through the patient’s medications with them has been very helpful. There’s a lot that can happen in those first few days.”

“There are often things that contribute to a patient bouncing back into the hospital that we don’t always ask about or patients are embarrassed to tell us,” adds Rastogi. “They may tell us, ‘Yes, I have plenty of food,’ and ‘Yes, my home is safe,’ but when somebody’s actually there with them, they can verify those things and uncover issues that need to be addressed.”

Lessons Learned

There’s plenty more to look at surrounding the Kaiser transition care program: How can the paramedic piece be best utilized? Can the follow-up visit be standardized? Is there value to home monitoring and telemedicine? Is there a role for palliative and hospice care?

Some of the lessons learned already are familiar to those who work cross-discipline, like the value of breaking down silos to collaborate.

“There’s been real benefit to reaching across our individual departments and becoming better coordinated with each other, so the patient experiences that seamless integration,” says Rice. “We all know what each other is doing and really have each other as an extension of our teams. We feel like we’re an extension of the nurses’ team and the nurses are an extension of our team, and we collaborate and talk on almost every patient we touch.”

Also necessary was really drilling down to identify readmission drivers. With this an independent physician reviewer (a Kaiser hospitalist not involved in the transition care program) assisted, examining readmissions and patients’ charts and “providing direct feedback to the whole work stream,” Rastogi says, “about what elements were being followed through with and missed, and how we could improve the process and get to a higher level of consistency. That third-person reviewer was very helpful.”

A lesson organizations may miss is to get patients involved and have their perspective inform each step—the one who assisted Kaiser Northwest was a quality improvement engineer by trade. There are also challenges surrounding data: Systems must be able to provide not only outcomes data, but data on individual element measures.

Rastogi cautions the transition care bundle elements work in concert and can’t be employed individually. “They’re all important to every patient,” he notes. “There’s no one element that’s more important than the others.”

That’s true—there are many aspects to tackling the readmission problem. And there are a lot of good ideas waiting to be tested and realized. Kaiser’s biggest lesson is don’t be afraid to try.

“You can sit in a conference room forever to try to get it perfect, but you really just need to try something,” says Hillstrom. “Just take the first step and try something, and that will give you something to build from. Here we are, six years later, and we’re still working on improving the program. So you’re never going to get it perfect; you just have to start somewhere.”