Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle

Abstract

In 2008, Kaiser Permanente Northwest identified the transition from hospital to home as a pivotal quality improvement opportunity and used multiple patient-centered data collection methods to identify unmet needs contributing to preventable readmissions. A transitional care bundle that crosses care settings and organizational functions was developed to meet needs expressed by patients. It comprises 5 elements: risk stratification, a specialized phone number for discharged patients, timely postdischarge follow-up, standardized patient discharge instructions and same-day discharge summaries, and pharmacist-supported medication reconciliation. The transitional care bundle has been in place for 6 years. Readmission rates decreased from 12.1% to 10.6%, Hospital Consumer Assessment of Healthcare Providers and Systems scores for the discharge instruction composite moved from below the 50(th) to above the 90(th) national percentile, average time to the first postdischarge appointment decreased from 9.7 days to 5.3 days, and error rates on the discharge medication list decreased from 57% to 21% (P<.0001 for all). The program, which continues to evolve to address sustainability challenges and organizational initiatives, suggests the potential of a multicomponent, patient-centered care bundle to address the complex, interrelated drivers of preventable readmissions.

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions

“…Thus, it is critically important to 1) identify high risk readmission factors, 2) develop strategic readmission prevention procedures, and 3) implement appropriate interventions among high-risk patients in a timely fashion [ 33 ]. Our readmission rate among all hospital admissions in this study was 11 % which is similar to others in the literature [ 34 , 35 ]. Although the average interval from index discharge date to readmission was 12 days, the peak time occurred within the first 7–10 days indicating that readmission prevention measures should be in place as early as the first week after hospital discharge.…”

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

“…For example, a RCT implementing electronic transfer of patient discharge forms reported improved post-discharge outpatient follow-up rates in a diverse group of patients (mean age 58) admitted to a small community teaching hospital in the USA [ 55 ]. Another study in the USA, deploying a transitional care bundle using patient-centred electronic data collection tools, supported the spread of transitional care across multiple sites and reduced medication errors in patients with a mean age of 54, half of whom had a high risk of readmission [ 54 ].…”

Effect of Pharmacy-Supported Transition-of-Care Interventions on 30-Day Readmissions: A Systematic Review and Meta-analysis

“…The flowchart of study inclusion is displayed in Figure 1. Of the 2611 citations reviewed, 56 studies 38,39,44-97 were included in the systematic review, and 32 of those studies were analyzed in the meta-analysis. 38,44…”

“…The studies used different designs, including: RCT (n = 18), prospective cohort (n = 14), retrospective cohort (n = 12), and controlled before-and-after (n = 12). In total, 61 903 patients were included, with individual study sample sizes ranging from 25 unique patients 63 to 21 375 unique patients; 58 4 studies 56,78,88,89 failed to report sample size. Usual care had varying definitions among the included studies.…”