“Kitchen Table – The Source of
Truth”
Karen Adams, RN, BSN
Geisinger Home Care and Hospice
and
Janet Comrey, MHSA, RN
Sr Consultant, Population Health
Geisinger Health System
May 17, 2012
“What is needed is a shift from a focus on providing excellent care
just within the walls of various clinical settings to understanding and
attending to the experiences of patients over time, across settings”
Birk,Susan : Reducing Hospital Readmissions,
Healthcare Executive. Mar/April 2012
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Every morning Henry wakes up, sits down with his cup of
coffee, bowl of oatmeal, and checks out the latest gossip
in the day’s newspaper. Alongside his bowl he lines up his
morning drill of medications; one pill for his heart, another
for his cholesterol, one funny shaped one he can’t
remember why he’s taking, a big vitamin his daughter said
he should take, and his daily aspirin for his aching knees.
Come dinner time he lines up his next round, asking
himself, “Did I take that one already?” or “Was I supposed
to take that one with food?” or “Did the doctor tell me to
wait until bedtime to take that one?” This is the battle
Henry faces each day. Chances are he’s taking at least
one or more of his medications inappropriately and runs
the risk of experiencing a number of negative side
effects…..
Aging & Disability resource Center, WI. (2011)
www.adrc-cw.com
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Why be concerned about Transitions of Care?
Readmissions increasingly represent quality indicator
One in five seniors are readmitted within 30 days
Up to three-quarters may be preventable
$15 billion to Medicare program
“The Billion Dollar U-turn”
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Jencks, Williams & Coleman, NEJM 2009
MedPAC, 2007
Taylor, H &HN 2008
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4|
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|5
Copyright Geisinger Health System 2012
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Recent Publications :
Dartmouth Atlas: “…there was relatively little change in 30day readmission rates from 2004 to 2009, regardless of
the cause of the initial hospitalization.”
JAMA: “Most current readmission risk prediction models
that were designed for either comparative or clinical
purposes perform poorly.”
Annals of Internal Medicine: “No single intervention
implemented alone was regularly associated with
reduced risk for 30-day re-hospitalization.”
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www.dartmouthatlas.org, Released September 28, 2011.
JAMA. 2011;306(15):1688-1698. Released October 19, 2011.
Ann Intern Med. 2011;155:520-528. Released October 18, 2011.
Copyright Geisinger Health System 2012
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Where is largest opportunity?
(Premier, inc.)
We should be
able to impact
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|
Quality Advisor™
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use or
distribution without
permission
Inpatient
data
All-cause
readmission
30 day- last 12 mos
Thirty Day Readmission Rate* by Discharge Disposition
CY11 to Any Provider
76% of patients were either discharged
to home or to home with home health
* All Cause Readmissions to same facility excluding Psych, Rehab, and
Deaths from the denominator
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|9
Copyright Geisinger Health System 2012
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Drivers of Reducing Readmissions
GOAL
KEY TACTICS
DRIVERS
Early identification of readmission risk
Screening
Readmissions
Care Mgmt:
Inpatient/
Outpatient
Team
Communications (IDTs)
Patient
Education/ Med
Rec
PostTransition Care
Target interventions based on risk level
Early DC needs assessment of high risk pts
DC Planning – choose best next care setting
Proactive Outreach programs
Seamless transition between IP & OP Care Mgt
Multi-disciplinary care coordination
Patient Activation and Engagement
Teach-Back methodology
Comprehensive Transition Planning
IP Pharmacist consult on high risk pts/meds
Post-DC Follow-up appt for EVERY patient
Instant communication of Transition Record to post-DC
providers/agencies
MH with tele-monitoring, follow up phone calls, SNF
management
Social issues addressed (non-compliance, ability to buy
|
meds, advanced directives)
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GHS Transitions Processes
Major Initiatives from January 2008 to the Present:
• Risk Screening
• Interdisciplinary Team Rounds (IDTs)
• Care Management Assessment/Workflow
• Proactive Outreach
• Kitchen Table
• Discharge Bundle
• ProvenHealth Transitions
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Readmission Risk Screening
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Readmission Risk Screening
Based on the premise that:
– Resources are finite
– One cannot bring all resources to bear on each patient
– Highlighting “High Risk” patients raises awareness within the health
care team
– Interventions focused on patients at highest risk for readmission
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Readmission Risk Screening – High Risk
Targets
Comprehensive care management assessment regardless of
perceived “discharge needs”
Transition care activation (one or more)
– Outpatient care management referral
– Pharmacist review of high risk medications
– Post discharge home care visit
Order primary care provider and/or specialist follow-up
appointment prior to discharge with reminders to admitting
physicians
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TOC Readmission Risk Screening Tool
The weight given to each question in this tool is based on that response’s influence on the
overall likelihood of patient’s readmission within 30 days
“YES” = point value designated for question
narcotics
“NO” = 0 points
Scoring guidelines:
0 – 2 Low Risk
3 – 7 Medium Risk
8 – 22
High Risk
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Screening
Potential
Score
Odds
Ratio
P-value
Age 65 or Greater?
1
1.24
<0.0001
Admitted from SNF or Requires Paid or Family Care
1
1.49
<0.0001
Currently has CHF, COPD, ARF, CRI, or is on dialysis
2
1.71
<0.0001
Takes more than 5 Prescription Medications
1
1.93
<0.0001
Takes Digoxin, Insulin, Anticoagulants, Narcotics or
ASA /Plavix
1
1.58
<0.0001
History of Wound Infection or Poor Healing Wound
1
1.62
<0.0001
History of Pulmonary Embolism or DVT
1
1.31
<0.0001
Uses Cane, Walker, Wheelchair or Person to get Around
1
1.46
<0.0001
Will be alone after discharge or unable to attain assistance
2
1.09
0.0787
Hospital Admit in Past 12 Months
5
2.19
<0.0001
On Disability
2
1.39
<0.0001
Patient Considers own Health
2
1.21
<0.0001 | 16
Question
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Screening
All patients screened
Nursing driven – ED
and floor
Surgical pre-admission
screening
37,735 patients
Two hospitals
Negative predictive
value = 90.8%
Resource management
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Readmission Rates by Screening Score
Feb 11 – Jan 12
Includes:
GMC
AGP4 IP BP6 IP
AGP5 IP BP7 IP
BP5 IP
BP8 IP
GP2 IP
HFAM 7 IP
HFAM 8 IP
GWV
CSU IP
MS3 IP
MS4W IP MS5E IP
MS5 IP
MS6 IP
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MS6E IP
PCU IP
Care Management Assessment/Workflow
and Proactive Outreach
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Care Management/Outreach
A full Care Management Assessment is completed for:
– Patients with a high risk of readmission based on TOC readmission risk screen
results
– Patients with any discharge planning needs that are to be arranged by Inpatient Care
Management staff
– Appropriate Patients who can be referred to :
• SNFists
• OP Case Management/Medical Home
• Kitchen Table program - one medication management home visit postdischarge for select population
An abbreviated screening is completed for:
– Patients with a low risk of readmission based on TOC readmission risk screen results
– Patients with no discharge planning needs including:
• Patients who will be discharged to home with no services that would be arranged
by Care Management staff
• Patients at the end of life who are expected to expire prior to discharge
Review of Readmissions that occur for preventable issues
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Kitchen Table
Medication non-adherence drives 10 to 25 percent of hospital and
nursing home readmissions (WHO, 2010)
Patients being discharged from the hospital who have a clear understanding
of their after-hospital care instructions, including how to take their medicines
and when to make follow-up appointments, are 30 percent less likely to be
readmitted or visit the emergency department than patients who lack this
information (AHRQ, 2011)
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GHS Home Medication Management Referral
Program – The Kitchen Table Program®
Home Care RN visit for secondary medication
reconciliation and patient education post-DC – HHC
RN coordinates w/ IP Pharmacist for questions/issue
resolution
Eligibility:
Pt screened as HIGH risk for readmission on TOC tool
Pt discharged to home setting with home health need
Pt not actively enrolled with ProvenHealth Navigator
Pt lives in GHC service area & agrees to home care visit
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Home Care Medication Management Model
Pharmacist
Home Care Nurse
Patient Referral
Doctor
Access EMR D/C Medication List
Collect Actual Medication List
Is there a
Discrepancy?
No
Yes
Potential
Harm?
No
Yes
Nurse calls Pharmacist
Fax List
to Pharmacist
Check for
Interaction
Can
Pharmacist
Resolve?
No
Consult
Hospitalist
Yes
Update Plan of Treatment
Educate Patient
Potential
Harm?
No
EPIC Message
to Nurse
Yes
Doctor
Recommendation
to Pharmacist
Verbal Order
to Nurse
Update EMR
Distribute Plan of Treatment
to PCP / Hospitalist
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Doctor Signs
and Returns
The Kitchen Table Program® Results
• 110 total enrollees
Readmission Rate (By Percent)
30
25.2
Kitchen
Table
25
20.2
19.8
Floor average
Platform
average
20
15
12.5
10.5
10
5
0
Not referred
Refferred all
cause
Referred
Unexpected
Percent by readmission
time-frame (Days)
60
50
40
25
25
8 to 14 days
15 to 30
20
0
Less than 7
Internal Data, FY 2011 pilot
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About Cost of Readmissions at GHS
• We estimate the average cost for a Readmission at Geisinger as $8,970 with an
average length of stay of 5.7 days during those readmissions
•Assuming a readmission rate of 18.0% for the high risk population, we would have
expected about 20 patients of the enrolled population (110) to be readmitted.
•Knowing only 12 Kitchen Table enrollees were actually readmitted, we assume 8
admissions were prevented.
• Assuming a cost of $100 per enrollee, providing Kitchen Table consultation for 110
enrollees equates to $11,000.
•Assuming prevention of readmission for 8 enrollees, using the above calculated
costs, we potentially have saved the system $60,760.00 and 46 bed days.
•How many more within the total population could we have prevented??
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ProvenHealth Transitions
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PCP F/U Visit
within 7 days
Post D/C
Phone CallRisk stratified
D/C Instruction
with Teach
Back
Readmission
Risk Score at
admission
Identified PCP
Identified
Care Team
Geisinger’s
ProvenHealth Transitions
12-point Bundle
(Proposal)
Early
notification
MyGeisinger &
Universal
Authorizations
Transition
Record
D/C Time Out
ADV DIR &
POLST
Med Rec for
High Risk
KT
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Summary
Systemic approach to transitions
Screening to effectively deploy resources
Engage health care team and patients/families
Plan post-acute follow-up
Deliver accurate information in timely manner
Engage patient longitudinally post-discharge
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Confidential and Proprietary
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Questions?
Karen Adams, RN, BSN
Geisinger Home Care and Hospice
Kladams@geisinger.edu
Janet L Comrey, MHSA, RN
Sr. Consultant, Pop. Health
Jlcomrey@geisinger.edu
Copyright Geisinger Health System 2012
Confidential and Proprietary
Not for use or distribution without permission