Background: Kaiser Permanente Roseville Medical Center is a 340 bed facility in Northern California.  Reducing readmissions has been a focus, and the current observed over expected rate is 0.77.  Starting from this relatively low readmission rate, our focus has been optimizing care for patients at high risk of readmission.

A retrospective review of all patients (n=1834) admitted with sepsis over 12 months was compiled, creating a database with 38 fields including criteria used for hospice intake.  Chi-squares identified three statistically significant factors: more than 3 hospital admissions during the past 12 months, pneumonia in the setting of chronic respiratory failure, and severe protein calorie malnutrition.  A patient with any one of these factors had a 26 percent chance of readmission within 30 days.  Furthermore, these patients were only 34 percent of sepsis patients, but made up 54 percent of all readmissions.

The inpatient palliative care consult service at Kaiser Roseville routinely visits with potential patients identified by the staff.  For a 3 month period, the potential patient list included all patients with more than 3 hospital admissions during the past 12 months, pneumonia in the setting of chronic respiratory failure, or severe protein calorie malnutrition.  While palliative care consults were completed on 43 patients, this group’s 30 day readmission rate was unchanged at 26 percent.  Reviewing the 11 patients who were readmitted, 3 were discharged to hospice and 5 transitioned to comfort care subsequently dying in the hospital.  It was also noted that several patients or their families had mentioned they were considering hospice, but wanted to try restorative care at the time of initial discharge.

Purpose: We attempted to reduce readmissions, by providing intensive follow-up after palliative consultations.

Description: During the subsequent three months, palliative care consulted as usual on 46 sepsis patients at high risk for readmission.  Of these patients, 12 indicated that they wanted a trial of restorative care prior to considering hospice.   The discharge planner was notified of this choice, and began conversations with the patient and family about how 24 hour caregiving might be arranged.  The patient’s primary care physician or skilled nursing facility attending physician was contacted by telephone with a discharge handoff noting the trial of restorative care.  Patients or their families also received telephone calls from a physician weekly for 4 weeks following discharge, which inquired about the patients’ health and medical needs.  Seven of these 12 patients (58%) were transitioned to hospice or comfort care at a skilled nursing facility without readmission to the hospital.

Conclusions:  Palliative care consultations may discover that the patient is considering hospice, but first wishes to continue a trial of restorative care.  Discussing arrangements for caregivers, notifying subsequent providers, and frequent telephone follow-up appear to have avoided unnecessary readmissions by initiating hospice or comfort care in the outpatient setting.