Redesigning the transition process cuts readmissions
Redesigning the transition process cuts readmissions
Patients, providers gave input on new practices
Kaiser Permanente's six-step process to improve transitions of care has resulted in reduced preventive hospital readmissions, an increase in the percentage of patients with physician appointments within five days of discharge, and raised patient satisfaction scores.
"Our 30-day readmission rates were better than average, but we knew some patients were experiencing fragmented care during transitions. We began the program as a pilot project in Portland, OR, and are rolling it out nationwide," says Carol Barnes, MS, PT, GCS, executive consultant for strategic programs, CARE Management Institute, Kaiser Permanente, Oakland, CA, who facilitated the transition improvement project.
Results vary among regions and medical centers, but every facility that has implemented the process has shown improvements, Barnes says.
The transition process includes a bundle of six critical elements for successful care transitions, Barnes says. They include making sure patients know who to call if they encounter problems after discharge; ensuring that patients have timely follow-up appointments with their primary care physician; making follow-up calls to patients after discharge; improving the medication management process; creating standardized assessments to determine patients' risk for readmission and post-discharge needs; and improving communication with post-acute providers.
Before Kaiser Permanente embarked on the project, the organization conducted hundreds of interviews with patients, family members, doctors, nurses, and other staff in hospitals and skilled nursing facilities.
"We started out thinking we knew a lot about what was wrong in the transition process, but the patients and family members gave us a lot of new insight into what was happening in the transition process and where the glitches were," Barnes says.
The team interviewed members by phone and in person and videotaped some interviews, producing a series of short video clips called "The Voices of Our Members" for the medical centers' staffs to view. "It makes a big impression when people can see members and hear about their experiences, rather than just reading a document," Barnes says.
They asked patients and caregivers what part of the transition process worked for them, what wasn't working well, what they needed at home, how they were managing their conditions, and what Kaiser could do to improve the transition process.
After all of the feedback had been collected, the organization assembled a team of front-line clinical and administrative staff, physicians, health plan leaders, and 10 patients and family members to come up with a plan to redesign transitions. A patient also served on the leadership team when the pilot project was implemented.
"We've always talked about patient-centered care, but now that we better understand what patients go through as they transition, it feels like we're really doing it," Barnes says.
Kaiser Permanente's six-step process to improve transitions of care has resulted in reduced preventive hospital readmissions, an increase in the percentage of patients with physician appointments within five days of discharge, and raised patient satisfaction scores.Subscribe Now for Access
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