Table Of Content

2011 Military Health System Conference Safe Transitions from Hospital to Home The Quadruple Aim: Working Together, Achieving Success Jann Dorman, Linda Trowbridge, and Carol Barnes January 26, 2011 Kaiser Permanente Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 1. REPORT DATE 3. DATES COVERED 26 JAN 2011 2. REPORT TYPE 00-00-2011 to 00-00-2011 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Safe Transitions from Hospital to Home 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION Military Health System,TRICARE Management Activity,5111 Leesburg REPORT NUMBER Pike, Skyline 5,Falls Church,VA,22041 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited 13. SUPPLEMENTARY NOTES presented at the 2011 Military Health System Conference, January 24-27, National Harbor, Maryland 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a. REPORT b. ABSTRACT c. THIS PAGE Same as 53 unclassified unclassified unclassified Report (SAR) Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 Today Time Topic Presenter 3-3:20 Introduction and Background Linda Trowbridge Readmission Diagnostic Evaluation Results 3:20-3:25 Video Linda Trowbridge 3:25-3:40 Moving from Evaluation to Carol Barnes Results 3:40-3:45 Discussion All 2011 MHS Conference 2 Session Objectives  Participants will be able to… - understand key drivers of unnecessary readmissions - describe the essential components to a patient centered transitions approach - identify key interventions that contribute to improved transitions and a decrease in unnecessary readmissions 2011 MHS Conference 3 More about Kaiser Permanente  8.7 million members  9 states + Washington, DC  32 hospitals  420 medical offices  14,000 physicians  160,000 employees  KPHealthConnect 2011 MHS Conference 4 What do we know about readmissions?  Readmissions are Frequent - 1 out of every 5 Medicare beneficiaries had an unplanned readmission within 30 days (NEJM, April 2009)  Readmissions are Costly - Total cost of unplanned readmissions for Medicare population estimated to be $17.4 billion in 2004 alone (NEJM, April 2009) - CMS reimbursement is changing – there are new incentives to reduce unplanned readmissions  Readmissions are sometimes preventable - Nationwide, between 9% and 48% of readmitted patients receive substandard care during or following the index hospitalization (Archives Internal Medicine 2000) 2011 MHS Conference 5 Transitions "Care transitions is a team sport, yet all too often we don't know who our teammates are, or how they can help." Eric A. Coleman, MD, MPH 2011 MHS Conference 6 Readmission Diagnostic Evaluation Results 2011 MHS Conference 7 NCAL Readmission Rates All Cause 30 Day Readmission Performance Northern California KFH Facilities - 65 and Over THE KP NCAL 65+ Oct08 - Sep09 NC KFH Average = 17.1% READMISSION RATE 30% 25%  is lower than the e g national average nta 20% e c er P n 15% o  has not changed si s mi d 10% much over time ea R 5%  varies across 0% icnednitveidrsual medical Santa Rosa Modesto Santa Teresa uth Sacramento Redwood City San Francisco Antioch Walnut Creek Vallejo Roseville Fresno Santa Clara Oakland Hayward San Rafael Sacramento Fremont South SF Richmond Stockton Manteca o S Note: readmission performance is not risk adjusted 2011 MHS Conference 8 Why are patients readmitted?  Systemic Drivers of readmissions are still not clearly understood - Administrative data like diagnoses reveals associations rather than explanations - Understanding why readmissions occur and which readmissions are preventable requires closer examination of the patient care 2011 MHS Conference 9