Transforming Care in an Integrated Health System

Benjamin K. Chu, MD, MPHPresident

Kaiser Permanente Health Plan/Hospitals Southern California Region

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Kaiser Permanente: The oldest group model health maintenance organization, serving 8.6 million people in 8 regions across the country

Kaiser Permanente Programwide

• 8.6 Million Members• 32 Hospitals• 420 Medical Office Buildings• 14,000 Physicians• 156,853 Employees• $40 Billion Annual Revenue• 600 – 700 Residents

and Fellows• $4 Billion Health Information

Technology Investment• 60 Years of Providing Care• Focus on prevention of

illness and disease

Kaiser Permanente’s capitated payment model places as much emphasis on keeping people health as it does on caring for members when they are ill.

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3.28 Million Members 13 Hospitals More than 120 Medical Office

Buildings 55,000 Employees 6,500 Physicians 280,000 Hospital Discharges 34,400 Babies Delivered Annually 17.7 Million Outpatient Visits 22.7 Million Prescriptions Filled 305,800 Annual Home Health Visits $14 Billion Annual Revenue Full implementation of electronic

medical record in all hospitals and medical office buildings

Kaiser Permanente Southern California: Who We Are

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A Care Model Systems Approach Leads to Improved Outcomes

Source: Adapted from the Chronic Care Model, Ed Wagner, MD, www.improvingchroniccare.org

Community

Health SystemHealth Care OrganizationResources

and PoliciesSelf-ManagementSupport

DeliverySystemDesign

DecisionSupport Tools

InformationSystemsSupport

Improved Outcomes

ProductiveInteractions

Informed,Activated Patient

Prepared, Proactive

Practice Team

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HEALTH PLAN MEMBERS

KAISER FOUNDATIONHEALTH PLAN

KAISER FOUNDATION

HOSPITALS

Southern California PERMANENTE

MEDICAL GROUP

Kaiser Permanente’s Integrated System Connects Health Plan and Health Care Services

• Kaiser Permanente has integrated finance and care delivery services

• This creates the ability to allocate resources where needed to achieve the best health outcomes for the patient

• Kaiser Permanente’s capitated payment model places as much emphasis on keeping people health as it does on caring for members when they are ill.

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Kaiser Permanente Is Transforming from a Traditional “Sickness Model” to Proactive Care That Helps Prevent Debilitating Illness

Proactive Care Processes Care Delivered by a Health Care

Team Care Integrated across Time, Place,

and Conditions Care Delivered through Group

Appointments, Nurse Clinics, Telephone, Internet, E-mail, Remote Care Technology

Self-Management Support that Is Integral to the Delivery System

What is required is a new patient-centric care model, which is characterized by:

In today’s complex health care world, in which chronic illness is a larger burden than ever before, a single physician cannot fulfill all the functions necessary to

optimize health outcomes for patients in a series of short interactions.

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The U.S. Health Care System Overall Is Terribly Fragmented and Patient Care Is Not Coordinated

Rehabilitation

Call CenterAdvice Center Skilled Nursing

Facility

Hospital

Urgent Care

Pharmacy

Laboratory

Emergency Dept.

Specialty CareOffice

Primary CareOffice

HospiceRadiology

Media/Web

Health Plans

DME

Home (Self-Care)

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Information Systems Allow Kaiser Permanente to Embed the “Right Thing to Do” into Each Point of Care

Member-Centered Care Management

Specialty Care• Reminder/Prompts• 24/7 availability of clinical information

• Access to Registry•Decision support tools

Primary Care• Reminder/Prompts• 24/7 availability of clinical information

• Access to Registry• Decision support tools

Rehabilitation Facility

Skilled Nursing Facility

Home• Outreach Letters• Telephone Outreach• Flu Shot Reminders• Healthphone• Healthwise Handbook• Member Web site•Remote Monitoring

Laboratory• Automated

Standing Orders

Pharmacy• Protocols• Alerts• Counseling

Health Education

Urgent Care•Reminders/Prompts

Emergency Room• Standing Orders• Protocols

Call Center/ Advice Nurse

• Scripts• Protocols

Hospital• Treatment Protocols• Standing Orders•Patient Safety Imperative

•Highly Reliable Care

Adapted from: Hyatt JD, Benton RP, Derose SF, JCOM, April 2002

Care/Case Management• Protocols

Information Systems Support Care Across the Integrated Continuum of Care and Contribute to a Better Understanding of Each Patient’s Health Needs

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Kaiser Permanente’s Care Management Support Provides Better Patient Management Using Evidence-Based Medicine

Patient Registry and Concurrent Tracking System• Identifies all members in the population• Risk stratifies population for targeting interventions and resources• Tracks and monitors each patient for key indicators (lab, pharmacy,

encounters, clinical indicators, etc.)• Easy Access (Web-based)

Care Management Systems• Flags/Alerts• Supports Telephone management and documentation

Supports Automated Clinical Decision Support and Practice Tools• In-reach/Outreach

Health Education and Self-Care Support

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Kaiser Permanente Clinical Information Systems Provide Better Patient Management Using Evidence-Based Medicine

Labs

Clinical Information

Systems

Hospital

Pharmacy

Outpatient Appointments

Outpatient Encounter

Membership

Emergency Department

Immunizations

RegistriesRisk stratification of populationIdentify subgroups needing specific carePatient management toolsTargeted panel listsPrompts, reminders for cliniciansLetters and automated telephone outreach to membersMonitoring and process improvement measures and reportsTargeted health education and self-care support

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Kaiser Permanente’s Registry for Chronic Diseases and Panel Management Provides Insight Across Disease Spectrums

Eight Major Clinical Registries: Asthma Heart Failure Diabetes Coronary Artery Disease Chronic Kidney Disease Cardiovascular Hypertension Panel Management

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Kaiser Permanente’s Registry for Chronic Diseases and Panel Management Provides Insight For Each Chronic Disease

Each member of the care team can access registry and panel management tools and play a role in addressing care gaps

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Kaiser Permanente’s Registry for Chronic Diseases and Panel Management Can Be Used for Physician Panel Management

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Kaiser Permanente Members Actively Participate in Care Through kp.org

KP HealthConnect Care Delivery Core

Outpatient

Scheduling

Registration

Inpatient

Scheduling

Pharmacy

Registration

EmergencyDepartment

www.kp.orgMember Web Portal

Clinicals

Billing

Billing

Clinicals

Make/Change Appointments

Send messages to doctor

Make payments

Refill prescriptions

Check lab results

Access health Information

Access medical record

On-line patient education, self-care modules and support provide

access to information 24/7.

Member contacts with the health system increase through new modalities• More than 2.4 million Kaiser Permanente members have access to secure health information

management features• 160,000 access kp.org daily

• More than 10 million test results viewed in 2007• More than 3.6 million secure e-mails sent to physicians in 2007

• 20,000 secure e-mails daily

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Electronic Medical Records Make Tracking Easy But Achieving Better Outcomes for Patients Requires Using This Information to Drive Change

Kaiser Permanente needed a way to use the information in the electronic medical record to impact the patient’s total health.

Every patient encounter in primary care and in specialty care creates an opportunity to provide total care.

Staff are charged with overseeing all aspects of patient care and determining what vital tests or screenings are missing.

Appointments can be made on the spot or referrals generated so gaps can be readily addressed.

This leads to proactive care instead of reactive care after someone presents with critical signs and symptoms.

Kaiser Permanente’s experience shows that patients who have the largest “gaps” in recommended care do not routinely visit their primary care physicians. Specialty clinics must play a role to achieve optimal results• Fewer than 40% of patients needing a mammogram or testing for

diabetes HbA1c visited their primary care physician

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• Phone calls• Letters• E-mail• Inbox Management

Office Encounter Management• Vital sign collection /

documentation• Identify and flag alerts for provider• Room and prepare patient for

necessary exams• Pre-encounter follow-up

Back Office Support

Pre Encounter Post EncounterOffice Encounter

Immediate• After visit summary,

after care instructions, follow-up appointments, Health Ed materials, how to access info on kp.org

Future• Follow-up contact and appointments per provider

Proactive Identification

• Identify missing labs, screening procedures, access management, kp.org status, etc.

• Provide member instructions prior to visit

• Contact member and document encounter in KP HealthConnect™

Proactive Encounters Have Revolutionized How Kaiser Permanente Provides Total Health

• Not all patients see their primary care physician.• Every office encounter has been redesigned to optimize each patient contact. • Areas of need are identified and acted on.• All staff have responsibility for patient’s total health.

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The Ability to Use, Not Just Store, Information Electronically Results in Better Outcomes

Proper use of surgical antibiotics results in fewer surgical site infections.

Higher screening rates result in more cancer detection at earlier stages

Better blood pressure control results in fewer heart attacks and hospitalizations for related diseases.

Better osteoporosis management results in fewer hip fractures among the elderly population.

Examples Include:

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• Panel Management• Pre-Encounter, Encounter Checklists• Proactive Care Gap Checklist• Proactive Encounter Performance Tool• Proactive Encounter SmartSets (KPHC)• Utilization Reports

Proactive Office Encounter:Tools for Staff and Physicians to Fill Care Gaps

Special tools and systems have been designed so each member of the care team can understand responsibilities and track results.

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Proactive Care Gap Checklist

Gaps in the patients care are identified through the use of flags.If there is a “Y”, an action is needed.

Member Information

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Outcomes: Breast Cancer Screening Rate (ages 52–69) – #1 in the U.S.

Kaiser Permanente Southern California is #1 HMO in the country for breast cancer screening because of ability to see who in the defined population has not had a mammogram and schedule an appointment (often the same day) no matter why the patient was being seen originally.

565 lives saved per decade 4,349 Stage 4 cases prevented per decade

78%

80%

82%

84%

86%

88%

90%

YE 2004 YE 2005 YE 2006 YE 2007 through 10/08

National 90th

percentile

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Outcomes: Colorectal Cancer Screening

Ability to view medical record electronically allow staff to see who in defined population needs an appointment for screening.

3,838 lives saved per decade

35%

40%

45%

50%

55%

60%

65%

70%

YE 2004 YE 2005 YE 2006 YE 2007 through 10/08

National 90th

percentile27% Increase

in 4 Years

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40%45%50%55%60%65%70%75%80%85%

YE 2003 YE 2004 YE 2005 YE 2006 YE 2007 through10/08

Outcomes: Controlling High Blood Pressure (ages 18-85)

Compliance with regular testing and medication are easily captured and reviewed.

4,890 lives saved per decade

National 90th

percentile

35.6% Increase in 4 years

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Outcomes: Osteoporosis Management

Proactive measures can reduce hip fracture rates by an average of 37.2 percent—and as much as 50 percent—among those at risk.

National 90th Percentile for Medicare is 30%.

25%30%35%40%45%50%55%60%65%

YE 2005 YE 2006 YE 2007 through 10/08

National 90th

percentile

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Outcomes: Decreased Hip Fractures by Almost 40% Due to Proactive Measures

Hip fractures in older women lead to many complications including:• Lack of mobility• Inability to provide self-care• Expensive nursing home care• Death

37% total reduction in hip fractures in older

women

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Selected Hospital Outcomes in Kaiser Permanente

50%55%60%65%70%75%80%85%90%95%

100%

3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08

Heart Failure BundleSCIP Composite

Kaiser Permanente Southern California has made dramatic gains in important hospital measures in less than two years.

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Better Hospital Outcomes in Kaiser Permanente Southern California

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

07Q3 07Q4 08Q1 08Q2 08Q3

Kaiser Permanente Southern California

consistently performs better than most in important

hospital infection-control measures: Bloodstream Infections and Hospital-

Acquired Pressure Ulcers.

NNSI National BSI Rate

0.00

0.02

0.04

0.06

0.08

0.10

3Q2007 4Q2007 1Q2008 2Q2008 3Q2008

KP Southern California BSI

Rate/1000 Line Days

KP Southern California HAPU Rate

California HAPU Rate

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Hospital Outcomes in Kaiser Permanente Southern California

50%

55%

60%

65%

70%

75%

80%

3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08

KP Southern CaliforniaUS Medicare Overall

Kaiser Permanente Southern California consistently performs better than the Medicare average for hospital standardized mortality rate.

* 3Q2008 Medicare hospital mortality not available

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Kaiser Permanente Has Higher Cancer Survival and Lives Saved Annually Compared to National Data

KP 5-yr survival

SEER 5-yr survival*

Lives saved/yr

Breast 92.3% 88.6% 107

Colon 72.9% 64% 132

Melanoma 97.9% 91% 76

* SEER = Surveillance Epidemiology and End Results, part of the National Cancer Institute. These data are for five-years survival rates.

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Kaiser Permanente Addresses the Larger Healthcare Needs of the Community

Focus on primary care and prevention, and addressing chronic disease requires looking at larger communitywide issues

Behavioral factors are as important as specific treatments: better diet, reducing smoking, addressing the epidemic of obesity, greater physical activity

Community education for adults and children in recognizing bad health habits and taking action to create a better health outlook

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1. Incorporate health into local planning decisions

2. Increase access to parks and green spaces

3. Improve public access and safety in recreation areas

4. Develop collaborations with schools

5. Establish safe routes to school

6. Promote menu labeling and making nutrition information available to consumers

7. Increase availability of healthy foods, including fruits and vegetables

8. Promote healthy eating in public facilities

9. Publicly recognize civic involvement and leadership

10. Healthy choices start with you

Healthy Eating Active Living Program Helps Make Healthy Choices Easy

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HEAL and Operation Splash in Southern California

healthy eating active living

Healthy Eating, Active LivingPartnership with The California Endowment (Healthy Eating, Active Communities)

HEAL grants are focused on policy and environmental change

Operation SplashSubsidized swim lessons, extended pool season, supplies

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Professional theatre troupe performances and workshops for 4th graders and parents• 227 performances• 571 workshops• 57K kids and parents

Now a computer game:www.kp.org/amazingfooddetective

The Amazing Food Detective: Working on better nutrition to help stem the rise of childhood obesity

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Farmer’s Markets at Medical Centers Working With Local Vendors

Farmer’s Markets include:Fresh produceCooking demonstrationsWellness literature

7 farmer’s markets at medical centers and Kaiser Permanente Watts Learning Center provide access to health foods for communities that do not often have easy access to fresh fruits and vegetables and health snacking alternatives.

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Kaiser Permanente Works with the Trust for Public Land to Encourage More Active Lifestyles

In Southern California, Kaiser Permanente has a three-year partnership with the Trust for Public Land. Through a $750,000 grant, the Trust is assisting underserved, park-poor communities with planning, land acquisition, and grant development.

The grant also funds planning and development of fitness zones – exercise equipment that people of all ages can use. Five fitness zones have been installed in five Los Angeles County parks in low-income neighborhoods with high rates of obesity.

Creates open space in park-poor neighborhoods and installs Fitness Zones.

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This old rail road right-of-way was along the southeast corridor of Los Angeles County.

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Here’s the same site and what it looks like today thanks to the Trust for Public Land.

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These “abuelitas” or grandmothers are working out in Belvedere Park in East Los Angeles. The Trust for Public Land developed the Fitness Zone model and works on matching grants to install the equipment in low-income neighborhoods.

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Kaiser Permanente launched an advertising campaign – called “Thrive” – which emphasizes a health message for the community