Reducing readmissions – lessons for England from Kaiser Permanante

In June 2010 Andrew Lansley announced in a major speech “..we’re going to ensure that hospitals are responsible for patients not just during their treatment but also for the 30 days after they’ve been discharged.” The NHS Operating Framework for 2011/12 states that hospitals will not be reimbursed for emergency readmissions within 30 days of discharge following an elective admission, and all other readmissions within 30 days of discharge will be subject to locally agreed thresholds, set to deliver a 25% reduction, where possible.

At the IHI conference in December 2010 Kaiser Permanente reported on their research into the causes of readmissions of all types within 30 days of an admission. They put in place an improvement programme that reduced readmissions across the board from 16% to 9% in 6 months.

What lessons can the NHS in England learn from this experience?

NHS Policy Context

In June 2010 Andrew Lansley announced in a major speech that “Over the last ten years emergency readmissions have increased by 50 percent. Not, it seems, primarily because patients were more frail, but because hospitals have been incentivised to cut lengths of stay and send patients home sooner – process targets creating risks for patients….. So in addition to getting rid of these targets – we’re going to ensure that hospitals are responsible for patients not just during their treatment but also for the 30 days after they’ve been discharged. It will be in the interests of the hospital for patients to be discharged only when they are ready and safe.”

The NHS Operating Framework for 2011/12 creates clearer incentives to drive integration between health and social care by giving PCTs responsibility for securing post-discharge support, with hospitals responsible for any emergency readmissions within 30 days of discharge. PCT allocations also include funding  for reablement and to support social care.  Hospitals will not be reimbursed for emergency readmissions within 30 days of discharge following an elective admission, and all other readmissions within 30 days of discharge will be subject to locally agreed thresholds, set to deliver a 25% reduction, where possible.

This policy is in response to an increase in emergency readmission rates over the last 10 years from about 7% to over 10%. The assumption is that the pressures to shorten length of stay are resulting in patients being discharged too early or with inadequate social and community health support. There are other possible explanations for the increase including the shift towards day case surgery (emergency admissions within 28 days of day case surgery are excluded from the figures as well as all cancer) resulting in the inpatient population being “sicker” and so more likely to be readmitted after discharge. There is wide variation across NHS trusts in England and nobody has done any detailed research across all acute providers in England into the preventability or otherwise of readmissions. However, what is certain is that this policy will reduce hospitals revenues in the next year compared to this; and that this will further squeeze providers.

At the IHI conference in December 2010 Kaiser Permanente reported on their research into the causes of readmissions of all types within 30 days of an admission. Kaiser Permanente, unlike NHS policy, is not  trying to correct hypothesised early or poorly planned discharge by the hospital. Kaiser are drived by the triple aim of i) effective clinical care ii) outstanding member experience and iii) efficient and reliable operation.  So their interest in reducing readmission is driven by a desire to deliver better clinical outcomes, give the patient a better experience by not readmitting them and to reduce costs. Their 30 day readmission rate is reported as being 16%, it is a measure of all readmissions within 30 days after inpatient treatment with no exclusions, and has been stable over time. Most readmissions are for a different reason than the original admission – the rate for the same discharge diagnosis across the two admissions is 5%. Of those patients who have a readmission within 30 days – 30% are dead within 6 months.

Kaider Permanente Study

They examined 600 readmissions using both traditional clinical audit techniques and also a video ethnographic approach to get under the skin of the problems. Three quarters of patients were readmitted for the same reason as their initial admission; typically respiratory, cardiac, renal chronic disease or dementia. Most had been readmitted through the ED and their primary care physician had not been aware that their condition had deteriorated. As a population they were generally frail with 60% needing help with the activities of daily living.

The study results were that 11% of readmissions were very or completely preventable and 36% slightly or moderately preventable. Some readmissions had multiple “opportunities” in the first admission to prevent a readmission  and those in the completely preventable category had up to 6! The breakdown was:

Contributory Cause Incidence
clinical care during admission 300
poor planning and co-ordination around transition 260
poor follow-up care 160
end of life care 160
poor medication management 90

The qualitiative data revealed that although 97% of patients received discharge instructions; they were very poor so that many patients reported that they did not know who to contact if they became ill; or if they did know a name then they didn’t have contact details. The discharge prescription and how to take medications was also poorly covered and a source of great confusion for patients. From the hospital’s point of view it was clear from staff behaviour that discharge occurred when the patient left the facility whereas for the patient it was when they got home.  The KP call centre was not authoritative and referred almost all patients who called it to the ED.  End of life care was handled particularly badly and while many patients expressed a wish to to know more details about their disease and its prognosis, doctors did not talk to them about end of life care and did not give them referrals to palliative care services.  Finally, it was clear that some readmissions occurred because patients couldn’t afford home care and this prompted the readmission.

Strategies for Reducing Readmissions

In England the reduction of emergency readmissions is ofteen seen as an issue of poor care pathway management. So the presumed answer is to work on improving the execution of specific care pathways.  Interestingly Kaiser’s analysis showed that individual conditions don’t contribute enough to the overall readmission rate  (the maximum represented 5%) so a diagnostic specific approach wouldn’t make an impact. As a result they had to look at changes across the entire system.

The improvement initiative had a number of bundled components:

  • risk stratify patients and focus on those at high risk
  • introduce an improved discharge planning process that includes the patient’s “my concerns” input
  • follow-up patients after discharge with registered nurse phone calls
  • focus on providing an understandable list of medications and validate once patient got home
  • standardised and appropriate follow-up
  • specialise post-discharge phone access for patients
  • refer to advanced care planing if appropriate

This was combined with a policy in which the hospital “owns” the patient for 72 hours after discharge. In this period a registered nurse will call the patient and these calls are successful about 70% of time, where the patient cannot be contacted by phone they are followed up in clinic. The post-discharge phone access is also manned by registered nurses who can create a 3-way conversation with the pyhsician if necessary. The main discussions have been about routine symptoms and the service hasn’t been abused.

The piloted improved the patient’s impression of the service and increased patient satisfaction. It also reduced readmissions across the board from 16% to 9% in 6 months. The improvement plan is now being rolled out across the KP system.

Conclusion

The Kaiser Permanente story on readmission is impressive but the details of what they did to improve their service are not, for me, the important lesson. They are the first to say that they haven’t “the answer”, are willing to learn from others, and that their bundle of initiatives is one step in an improvement journey.

I would identify three key learning points:

  1. A philosophy, the triple aim, which guides their improvement approach – policy doesn’t come from politics. So their objective is to reduce all unnecessary readmissions not just to reduce readmssions that are “bad” because they are presumed to be due to hospitals discharging too early.
  2. A research-driven approach that asks questions and collects evidence, and then uses that evidence within a structured quality improvement approach to pilot focussed improvement initiatives
  3. An evidence based philosophy that rolls out quality improvement approaches once they are demonstrated to work in pilot and then starts the cycle again to effect further improvements

I would much prefer to see NHS Trusts adopt an approach to readmissions that was rooted in a similar philosophy to Kaiser Permanente’s triple aim. I fear rather that we’ll see the management of a readmissions measure that is:

  • selective because of the exclusions in the measurement of readmissions, and
  • is at risk of being “gamed” to ensure that the Trust maximises its income.

After all I know which system I’d want to be in as a patient and I know which system will be the better one in ten years time.

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