Readmissions

'You Don't Have to Be a Kaiser' to Reduce Readmissions

By Mark Taylor

Ben Kitagawa, a 90-year-old Southern California heart failure patient, was once a"frequent flier" who was admitted two to four times annually to local hospitals for nearly a decade. But the Kaiser Permanente member and retired postal worker says he received few benefits from his repeated hospital readmissions.

"I didn't like going to the hospital so much," says Kitagawa, who lives alone in Sal Beach, Calif., about 25 minutes from the Kaiser Permanente South Bay Medical Center in Harbor City.

"He was in and out of the hospital a lot," says Kitagawa's home caregiver, nurse's aide Maribel Jorge."He would have shortness of breath or retain water and go to the hospital. We'd have to sit and wait for hours."

After enrolling in the Kaiser Permanente Heart Failure Transitional Care Program, Kitagawa has been able to receive most care as an outpatient living at home."Now we know how to handle it," says Jorge."All it takes is a phone call. They adjust his medication or do what's needed."

Kitagawa, one of 300 active heart failure patients enrolled in South Bay's program, is pleased with home care."A nurse comes every week to look after me. Maribel is my lifeline and Kaiser is her lifeline," he says.

Linda Aratani, R.N., South Bay's congestive heart failure care manager, says Kitagawa responds well to the patient education and monitoring that's allowed him to stay home."A few years ago we referred him to hospice because we thought we were going to lose him," she says of Kitagawa, who's suffered both a heart attack and a stroke."But they discharged him because he was doing so well and lived longer than the six-month hospice limit."

Aratani says instead of traveling to the ED or calling 911, Kitagawa and Jorge now call the program when his symptoms flare up."We've been able to keep him stable at home. His last hospitalization was over a year ago. He went to the ER in 2008—but for a nose bleed, not heart failure."

She says heart failure patients receive home nurse visits within two days of discharge. Nurses review medications with the hospital pharmacist to make sure they match up. Kaiser launched the program in 2007 to study and retool its discharge process and improve transitions between care settings.

Lowering readmissions was a tangible side benefit, says Jann Dorman, senior director of Kaiser's Care Management Institute based in Oakland. Several years ago, Kaiser realized that successful care transitions are critical for all members, but particularly the sickest and most vulnerable who suffer repeated hospitalizations."We knew from experience there was an important improvement opportunity there," says Dorman, who began by defining a holistic approach to member care from admission to 30 days from discharge.

Kaiser initiated an ethnographic research study of members, interviewing 200 at three Kaiser Permanente hospitals over six months."We wanted to understand what they experienced and how we could work collaboratively with our members to have them stay safely at home after a hospitalization," she says.

The ethnographic research informed Care Management Institute's work in refining care management."It's a very powerful way to bring our members' voices into every aspect of what we do to improve care delivery across Kaiser Permanente," Dorman says, adding that many strategies are needed to care for someone recovering after hospitalization, such as developing a patient-friendly medications list and offering a Web-based portal with medication information. During the interviews, Kaiser CMI staff learned something else valuable: the concept of"one foot out the door."

"We do all this teaching and preparation and education before the patient is discharged and we put out a lot of information, but it turns out that is not the best time to communicate that information for many of our patients," Dorman explains."They told us they have one foot out the door and will say anything to get out, which is why we've been looking at follow-up as an important opportunity to reinforce teachings and make sure patients have the information when they need it, usually once they get home."

Kaiser focuses on discharge planning during admission, particularly for planned procedures that might require physical therapy, rehabilitation and patient education. For unplanned admissions, Kaiser assesses the risk of rehospitalization at admission and red flags some higher risk patients.

Eventually, the Transitions of Care Program will spread throughout Kaiser's system, but Dorman says the knowledge can apply to other hospitals with different care delivery models.

"You don't have to be a Kaiser or an integrated delivery system to do this. Every hospital can understand the risks of hospitalization and assess its patient care plan. Every hospital can review and improve its discharge process and look at its 30-day readmission rate, review charts and fine-tune procedures," she says."To do transitions well, we don't need new machines or sophisticated technology. We just need to truly understand the patient needs and choices, include their caregivers, take an honest look at what's going on with readmissions and do our best to meet those needs."

This article 1st appeared in the January 2010 issue of HHN Magazine.

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