Readmissions Reduction Effort at Kaiser Involves Cameras

When some chronically ill patients are readmitted within 30 days at selected Kaiser Permanente hospitals, cameras start to roll.

"What do you think caused you to end up in the hospital again?" Kaiser staff ask, in words to that effect. "When you left the hospital, did you understand the purpose for taking each of the medications? Did you have any difficulty getting in to see the doctor after you left?" "How did you prepare your meals, and what did you eat?"

Some of the patients just sat there, not knowing how to answer. "I don't know. Ask my wife, she takes care of all that," said one.

Caregivers and social scientists, armed with handheld video cameras, are part of Kaiser's novel "video ethnography" team in California, an effort to understand the system's care process from beginning to end, with all its wrinkles, cracks, and failings, in order to improve care and prevent readmissions going forward.

They don't stop there.  Team members interviews pharmacists, home care providers, nurses, and physicians as well.

They also visit patients' homes to see how medications were managed, and  talk with home health aides and family members to get a sense of all the problems that brought patients back to the hospital (and probably would again and again unless the system's issues were resolved).

Then they shares the video and interviews with the care team, to show how those patients and caregivers experience the process, all along seeing ways to improve.

In the initial projects in California, Kaiser didn't learn just one lesson. It  learned 42, explains Estee Neuwirth, director of field studies at Kaiser Permanente.

Neuwirth and Kaiser Permanente colleagues talked about their video ethnography efforts at last week's Institute for Healthcare Improvement forum in Orlando.

Neuwirth emphasizes that the projects have yielded a wealth of information that was impossible to obtain through chart review alone.  In one project focused solely on Kaiser Permanente's South Bay Medical Center in Harbor City, near Los Angeles, video ethnography combined with other efforts was "key" to reducing readmissions from 15.7% to 9% in a recent six-month period.

Kaiser Permanente has a huge incentive to get this right. Although its readmission rate for patients over age 64 is 17.1%, far lower than the national average of 20% to 25%, the system manages nine million lives in eight states, and operates more than 30 acute care hospitals.  "We saw an opportunity to strengthen the quality of our care even more by addressing gaps," Neuwirth says.

In addition to the desire to improve care, now that the age of federal penalties for excessively high risk-adjusted readmission rates in Medicare patients is near, there’s a lot of money at stake too.

"With video, you capture the whole process; how people are doing things. We know that what people say they do and what they actually do are sometimes different," Neuwirth says.

In one project involving a deep dive into 600 cases of patients who had a 30-day readmission across 20 Northern California hospitals, "potentially preventable cases” each contained an average of 6.6 missed opportunities to prevent a readmission, according to a slide presentation by Paul Feigenbaum, MD, Kaiser's Northern California Medical Director of Hospital and Continuing Care Programs.

Neuwirth, Feigenbaum and the team have developed presentations, videos of patients and caregivers for internal quality improvement, as well as a tool kit with a step-by-step guide for other hospitals and health plans that wish to use video ethnography for change.

Providers who reviewed the case studies of the 600 patients concluded that 55 of their readmissions, or 11%, were "very or completely preventable" according to one of Feigenbaum's slides, and an additional 36% were slightly or moderately preventable.  That's a lot of potentially avoidable, not to mention costly care.

They realized that far too many patients don't understand why they're taking medications, or think they may be taking too many. "Some store all their, new and old prescriptions in shoeboxes to organize how they take their medications," Neuwirth says. Concurrent medication reconciliation with a home health nurse, a pharmacist, and the patient was one solution that led better medication management.

For example, Neuwirth says "teach back," a process by which patients are asked to verbally repeat their discharge plan instructions, was one important change in procedure that resulted from the video experience.

"And we realized that a lot of patients, particularly those with chronic conditions like congestive heart failure, need referrals to a dietician once they go home, so they can understand what we mean when we ask them to limit salt or fluid intake. We weren't always fully leveraging those resources," she says. “By talking with patients and observing how they live we came to better understand what they need and how we as a system could better wrap our arms around those needs.”

Lastly, they realized that many patients had unrealized psychiatric and social support issues. They said they found five major categories of missed opportunities that may have contributed to readmissions, the biggest of which dealt with clinical care. For example, for nearly 120 of those 600 discharged patients the medical condition was not optimally managed or monitored closely enough.

They found other major categories of missed opportunities, such as the need to need to improve home transition planning and care coordination, follow up care, end of life explanations, advance directive care as well as medication management.

Patients told them, for example, that they "did not know how to reach their doctors, saying "I don't even know who to call about this pain," or that when they were discharged, they were given 10 phone numbers to call.

A big lesson was learned about patients with end stage diseases, some of whom were not referred to palliative care or hospice. Because of that, some patients ended up back in the emergency department who didn't need to be there, Neuwirth and Feigenbaum said. In a slide show presentation on their report, they quoted physicians saying they didn't bring up palliative care or hospice because they thought such a referral:

• "Would not be well received" by the patient or family
• "It's someone else's job," (such as the oncologist.)
• There was "no time"
• "It didn't occur to them"

Moreover, almost half of physicians who reported that their patient would benefit from an advance care program had not referred their patient to one.

One issue was the perception by some patients that they didn't understand or weren't given a better explanation about the advanced stage of their illness.

According to Feigenbaum's presentation, one response from a patient who was readmitted was, “If we had known about Hospice we would have chosen that.”

Said another: “When I finally got the information I was shocked and had no idea; it would have helped to know sooner.” Said a third patient: [The doctor] may not be telling the complete truth regarding my diagnosis of cancer.

The late Sir William Osler, MD, the so-called "father of modern medicine," used to tell young doctors to "Listen to your patient, he is telling you the diagnosis."

By taking video of the patient and the whole caregiver team through this process, in the home as well as in the hospital, it may just be that Kaiser Permanente has made a major improvement upon that advice.

See Also:
Medicaid Status, Race Linked with Hospital Readmissions
Depression May Contribute to Hospital Readmission Risk
Hospitals struggle to reduce readmissions for chronically ill
4 Ways Hospitals Can Avoid Readmissions
Reducing Readmissions: Are Quality Payments a Carrot or Stick?