Kaiser hones hand-offs from hospital to homes

Preventing defects leads to less readmissions

Just as it standardized clinician-to-clinician hand-offs, Kaiser Permanente recognized the importance of the hand-off for the patient from hospital to home. Working to standardize the communication needs therein was Carol Barnes, MS, PT, GCS, principal program consultant with Kaiser's Care Management Institute.

The "couple-year" initiative, she says, began with a root-cause analysis of the reasons patients were coming back to the hospital. "We interviewed hundreds of patients and captured some of them on videotape. So we have a member voice library where our patients would tell us about their experience with the transitions," she says. And then the team sought to answer the question: "How would we redesign it to make the experience better for our patients and allow them to stay safely at home to prevent unnecessary re-hospitalizations?" she says.

The system picked its northwest region to test and redesign the process. What the team learned from its analysis was the cause was not one thing, even though patients see the hospital stay as one episode, Barnes says. The team set out to and later created a five-element bundle to improve the transition.

One of the foundations to a successful hand-off, the team determined, is that it is an "accurate and timely exchange of health care information," Barnes says. The hospital physicians, in collaboration with the primary care physicians, created a standardized discharge summary to complete before the patient leaves the hospital and now is part of the system's electronic medical record system.

"So before that patient leaves or as that patient leaves, that information is available to all subsequent providers that are going to provide care. And I want to emphasize the work standardized here because it's a really important piece of it," Barnes says. Prior to having that tool, she says, physicians would record too much information, while others would record not enough.

"So now every patient that leaves the hospital, the discharge summary looks the same, and it starts out with the important things we think you need to follow up on right upfront," she says. So first, it would include the patient was admitted here and discharged there. Secondly, it addresses the patient's risk of readmission, and then what the patient needs to know. "At Kaiser, we have complex predictive models available to us, but they wanted it easily available for the people treating the patients in the hospital."

A patient is considered high risk if he or she meets any of the following criteria:

  • he or she has had a prior separate readmission in 30 days;
  • the patient has heart failure;
  • the physician caring for the patient at the hospital thinks he or she is at high risk.

"Those three things together currently are identifying about between 10 and 15% of patients at high risk," she says. If a patient has had a prior admit or has heart failure, it is highlighted in the electronic medical record (EMR) so the physician knows. Now every patient who leaves the hospital is stratified as low, medium, or high risk for readmission. In addition, care is tailored based on that category. "It's one thing to identify the patient as high risk, which in and of itself is valuable, but in this particular region, high-risk patients get something different. And their care is different. So they get a sooner appointment, they get a nurse to follow them for 30 days, and they get the pharmacist to review their medications."

The third element of the bundle — after the standardized discharge summary and the risk stratification — is follow up. All patients who leave the hospital receive a "transition RN call" within 48 to 72 hours. That RN is based in the primary care office. A different person follows up on surgical patients.

If it's a high-risk patient, a nurse will follow him or her for 30 days. High-risk patients are scheduled for a primary care visit within five days of discharge; those without an unusual risk get one in at least 10 days. The goal, she says, is to get all patients a visit scheduled within five. "As of today 53% of all patients leaving this hospital have an appointment within five days," she says.

The fourth issue the team tackled was medications. In interviewing patients, Barnes says, the team found that many don't absorb the information they're given while they're still in the hospital — whether that's because they're still recovering from surgery, they're already on medications that affect cognition, or other multiple reasons. "Until they actually have to use the meds at home, that doesn't hit them how important it is. So in this bundle, they built medication reconciliation across the continuum," she says.

Pharmacists review medications for all high-risk patients in the hospital. Using the risk criteria the team developed, pharmacists now check about 37% of the cases. The pharmacist also calls the high-risk patients once they are home and works in concert with the RN in charge of follow up.

Before the redesign, patients were given numbers to call for problems once they were home. The most common number, Barnes says, was 911. "Often that would be the only phone number on there or we would give the patient a list of 20 phone numbers and [tell them] pick which one to call. So what our patients told us is they couldn't figure out who to call. That sounds so basic, but we were kind of missing that basic thing in this region, so we got a special transitions number and that number goes into the call center where today they are answering 80% of the calls in under a half minute," she says.

The hospital physicians took ownership of caring for patients between the time they leave the hospital and go to their first follow-up visit with their PCP. If the nurse who handles the calls cannot answer a question, she transfers the patient to the hospital physician. "The patients love it because they can get somebody right away, the nurse feels she is being very helpful, and then she has the ability to get either physician or pharmacist input right away," Barnes says.

Now, the average number of days before a follow-up visit post-discharge is down, 30-day readmission rates are trending down, and HCAPS patient satisfaction rates are going up, Barnes says.

[For more information, contact:

Carol Barnes, MS, PT, GCS, Principal Program Consultant, Care Management Institute, Kaiser Permanente. E-mail: carol.ann.barnes@kp.org.]