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

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.

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Objective: To understand factors leading to all-cause 30-day readmissions in a community hospital population.

Research Design: Structured case series of 537 readmissions using chart reviews, interviews with treating physicians, patients and family caregivers, and overall case assessment by a nurse-physician team.

Setting: Eighteen Kaiser Permanente Northern California hospitals.

A multidisciplinary approach to transition care: a patient safety innovation study.

Introduction: Patients with complex medical care needs often embark on multiple care transitions over an extended period of time. As these patients or their caregivers often become the chief source of communication for complex medical situations, each transition can create an opportunity for health care errors. Combining the efforts of the established departments of Chronic Care Coordination (CCC), Clinical Pharmacy Call Center (CPCC), and Continuing Care, Kaiser Permanente Colorado created programs to further safe care transitions.