Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.
A redesigned inpatient care model based on Toyota Production System principles uses daily multidisciplinary clinical team visits, individualized care plans, and facility and staffing changes to reduce costs and average length of stay and improve adherence to recommended care processes, nurse productivity, and patient, staff, and physician satisfaction.
As part of Kaiser Permanente's Care Management Institute's video ethnography approach, provider teams interview patients about their care experiences, leading to the development of many quality improvement projects that have resulted in better care processes and outcomes.
A collaborative medication review process involving physicians, nurses, and pharmacists virtually eliminates medication errors and significantly reduces readmissions in patients discharged to a nursing home.
A telepharmacy program enables offsite pharmacists to review and approve medication orders in 14 hospitals, leading to expanded hours of service, reduced order processing times, enhanced pharmacy services, higher nurse satisfaction, freed up pharmacist time, and more than $1 million in annual cost savings.
A hospital uses a multidisciplinary team, standing orders and reminder systems, manual medication reconciliation, and system-wide quality improvement to significantly improve performance on core measures for heart attack, heart failure, pneumonia, and surgical care.
An electronic medical record–based system features “soft” and “hard” stop functions designed to ensure that clinicians perform medication reconciliation, leading to a rapid, significant, and sustained increase in adherence rates.
Health system pharmacists telephone recently discharged patients to complete medication reconciliation and provide medication-related education, leading to significant reductions in readmission rates and high levels of patient satisfaction.
Pharmacists, pharmacy students or residents, and volunteers conduct clinics at primary care practices that help elderly, low-income patients access appropriate, cost-effective medications.
Care staff use software-based protocols to screen older clients' medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects, leading to more appropriate medication use and fewer cases of duplicative medications.