February 8, 2022

Readmission rates fall when care teams follow care pathway

Patients who transition from a skilled nursing facility to home are proven to be safer when Kaiser Permanente’s 6-point plan is used.

Mary Rix still remembers how she felt when she left the skilled nursing facility to return home after cancer surgery 7 years ago. “At discharge, everything can seem overwhelming, especially if you’re exhausted or not feeling well. Everyone knows you don’t get any sleep — whether you’re in the hospital or a skilled nursing facility,” she said. “When staff ask you if you have questions, you can’t think of them at the time.”

Many hospitalized patients go to skilled nursing facilities to continue recovering after they’ve had a serious illness, injury, or surgery. It’s a midway stop where they are likely to receive rehabilitative services, such as physical, occupational, or speech therapy. When patients are well enough to transition home, they receive detailed care instructions — and in many cases, medications — to continue the healing process.

“It’s a high-risk population at a high-risk time, especially for those with complex needs,” said Preston Peterson, MD, medical director for the skilled nursing facility program for Kaiser Permanente in the Northwest. “So many changes are happening, and patients are often dependent on at-home caregivers, either formal or informal, to help with medications, transportation, meals, and so forth.”

When Rix, a nurse for more than 40 years, returned home, she kept thinking about how the transition process could be improved for patients. She reached out to her Kaiser Permanente doctor to share her ideas and learned that Kaiser Permanente researchers were already exploring this topic. She was invited to become the patient advocate advisor in a pilot project aimed at improving the quality and safety of the discharge-to-home process.

Mary Rix, a nurse in the Kaiser Permanente Northwest Region
Mary Rix, a nurse at Kaiser Permanente for more than 20 years, used her personal experience to improve the quality and safety of the discharge-to-home process.

Readmission rates and medication errors decline

Researchers at Kaiser Permanente in Oregon sought to understand why skilled nursing facility patients were readmitted to the hospital at a higher rate (approximately 1 in 5) than patients who were readmitted after being discharged from hospital to home — and what they could do about it.

They developed and piloted a 6-point plan.

  • Risk identification: Clinicians determine the highest-risk patients who are about to be sent home and design a care plan accordingly.
  • Clear discharge summary: Before discharge, all plans and medications are communicated to the patient in one easy-to-read, personalized document.
  • Transition hotline: Patients are given a prioritized toll-free direct number they can call 24 hours a day to speak to a specialist or advice nurse.
  • Medication assessment: Before discharge, a transitional pharmacist calls or visits the patient to make certain medications and discharge instructions are correct.
  • Post-transition contact: Within 72 hours, a transition nurse contacts the patient, making sure any discrepancies or gaps are addressed.
  • Follow-up appointment: Before discharge, a follow-up appointment (either by phone, video, or in person) is scheduled, usually within 7 days.

“The goal of this program was to bolster the communication between the patient and the caregiver,” Dr. Peterson said. “The call with the transition nurse surfaces questions, identifying anything that needs to be escalated, and checks for understanding about the medication plan.”

The result? The program reduced 30-day readmission rates for this population by 44% and medication errors at discharge by 91%.

‘The power of Kaiser Permanente’

Fully recovered from her cancer surgery, Rix is engaged in her retirement community activities and enjoys being editor of the monthly resident newsletter. She is proud of her work to help Kaiser Permanente improve the transition from facility to home.

This program demonstrates the benefit of Kaiser Permanente’s integrated model, which facilitates seamless coordination of care teams (primary care, pharmacy, physical therapy, and more) to enhance the patient experience and improve safety and quality of care. “When being discharged from a skilled nursing facility, it’s important to have a team coordinating your care. It’s the human touch — those personal interactions — that really matter,” said Rix.

Dr. Peterson agrees. “This project really highlights the power of Kaiser Permanente in terms of being an integrated system,” he said, “and being able to design care in a way that nobody else has done.”