title: The readmission reduction program of Kaiser Permanente Southern California-knowledge transfer and performance improvement.
abstract: In 2011, Kaiser Permanente Northwest Region (KPNW) won the Lawrence Patient Safety Award for its innovative work in reducing hospital readmission rates. In 2012, Kaiser Permanente Southern California (KPSC) won the Transfer Projects Lawrence Safety Award for the successful implementation of the KPNW Region's "transitional care" bundle to a Region that was almost 8 times the size of KPNW. The KPSC Transition in Care Program consists of 6 KPNW bundle elements and 2 additional bundle elements added by the KPSC team. The 6 KPNW bundle elements were risk stratification, standardized discharge summary, medication reconciliation, a postdischarge phone call, timely follow-up with a primary care physician, and a special transition phone number on discharge instructions. The 2 additional bundle elements added by KPSC were palliative care consult if indicated and a complex-case conference. KPSC has implemented most of the KPNW and KPSC bundle elements during the first quarter of 2012 for our Medicare risk population at all of our 13 medical centers. Each year, KPSC discharges approximately 40,000 Medicare risk patients. After implementation of bundle elements, KPSC Medicare risk all-cause 30-day Healthcare Effectiveness Data and Information Set readmissions observed-over-expected ratio and readmission rates from December 2010 to November 2012 decreased from approximately 1.0 to 0.80 and 12.8% to 11%, respectively.
authors.affiliation: Southern California Permanente Medical Group Co-Lead for the Complete Care Program and Care Management Institute Physician Lead for Total Health. E-mail: philip.j.tuso@kp.org.
authors.forename: Philip
authors.initials: P
authors.lastname: Tuso
authors.forename: Dan Ngoc
authors.initials: DN
authors.lastname: Huynh
authors.forename: Lynn
authors.initials: L
authors.lastname: Garofalo
authors.forename: Gail
authors.initials: G
authors.lastname: Lindsay
authors.forename: Heather L
authors.initials: HL
authors.lastname: Watson
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Lenaburg
authors.forename: Helen
authors.initials: H
authors.lastname: Lau
authors.forename: Brandy
authors.initials: B
authors.lastname: Florence
authors.forename: Jason
authors.initials: J
authors.lastname: Jones
authors.forename: Patti
authors.initials: P
authors.lastname: Harvey
authors.forename: Michael H
authors.initials: MH
authors.lastname: Kanter
mesh_terms: D002140:California; D003266:Continuity of Patient Care; D003695:Delivery of Health Care; D006801:Humans; D006278:Medicare; D059065:Medication Reconciliation; D010351:Patient Discharge; D010359:Patient Readmission; D058996:Quality Improvement; D012017:Referral and Consultation; D014481:United States