A1/B1: Complete Care Model: Transforming Chronic and Preventive Care

Transcription

1 A1/B1: Complete Care Model: Transforming Chronic and Preventive Care Michael Kanter, MD, Medical Director, Quality & Clinical Analysis, Kaiser Permanente Regional Quality and Risk Management Gail Lindsay, RN, Director Clinical Operations - SCPMG, Kaiser Permanente These presenters have nothing to disclose. Every patient. Every visit. Every one. Every place. Every time. Objectives Discuss the implementation of systematic care in a delivery system. Understand the philosophy of the complete care model, provide key concepts of improvement of care integration, and assess whether the complete care model can be aligned with delivery system culture. Distinguish between the roles of systematic care and individualized care and identify strategies and tactics to increase person-focused care delivery. 2 1

2 Joint Commission Journal on Quality & Patient Safety November 2013; 39(11): Tactics for Managing Change 4 2

3 HEDIS Results 5 6 3

4 Disparities in control of blood pressure, cholesterol, and glucose for blacks in Medicare were eliminated [by Kaiser Permanente] in New England Journal of Medicine; 371:24, NEJM.ORG Racial and Ethnic Disparities among Enrolees in Medicare Advantage Plans John Z. Ayanian MD, etal December 11,2014 The IHS[Kaiser Permanente] approach to care is associated with higher levels of evidence-based medicine, improved survival, and reduced colon cancer disparity gaps. Journal of Clinical Oncology Published Ahead of Print on January 26, 2015 as /JCO How Do Integrated Health Care Systems Address Racial and Ethnic Disparities in Colon Cancer? Kim F. Rhoades, et al 8 4

5 SCAL Complete Care Person Focused Total Health Proactive, team approach Focuses on person, not just the presenting problem or the primary health concern 9 Prevention Acute/ Sub-acute Kaiser Permanente Complete Care Continuing Care (Palliative, End of Life, etc.) Chronic (HF, DM, CVD, HTN, etc.) 10 5

6 Urgent and Emergent Care Ambulatory Care Kaiser Permanente Complete Care Inpatient Care Continuing Care 11 Complete Care Every patient. Members with Chronic Conditions Complete Care Functions & Systems Every visit. Every One. Every place. Every time. 12 6

7 Complete Care Team Without Walls Healthcare team works across traditional boundaries Across the care continuum, organization and departmental hierarchies Integrated with those directly involved in the care process 13 Complete Care Model Person Focused Total Health Organization Focused to the patient Patient Focused for the patient Person Focused with the person 14 7

8 Continuum of Complete Care Pre Visit Visit Discharge /Post Hospitalization PERSON Post Visit Admission/ Hospitalization Pre Hospitalization/ Emergency Visits 15 KP SCAL Complete Care Medical Surgical Maternal Child 16 8

9 Medical Complete Care Asthma Breast Cancer Cervical Cancer CAD CKD Colon Cancer COPD CVD Depression Diabetes Geriatrics Hepatitis C HF HIV Hypertension MS Obesity Osteoporosis Pneumonia Rare Diseases Sepsis VTE 17 Surgical Complete Care Bariatric AAA Joint Prostatectomy 18 Surgery Replacement 9

10 Maternal Child Complete Care Pregnancy Breast Feeding 19 Alcohol Domestic Violence Immunizations Physical Activity Smoking Cessation Weight Management 20 10

11 WELLNESS COACHES 21 Proactive Encounter Proactive Panel Management Care/Case Management Proactive Office Support 22 11

12 Proactive Office Encounter (POE) Pre Visit Proactive Identification Identify missing labs (A1c, LDL, microalbumin), screening procedures, access management, KP.org status, etc. Provide member instructions prior to visit Contact member and document encounter in HealthConnect TM Visit Office Encounter Pre-encounter follow-up Vital sign, history, social, demographics, medication review Identify and flag alerts for provider for screening and uncontrolled chronic conditions Room and prepare patient for necessary exams Post Visit Immediate: After visit summary, after care instructions, followup appointments, health ed materials, how to access info on KP.org Future: Follow up contact & appointments per provider 23 Making the Business Case for Specialty POE Opportunities for Breast Cancer and Diabetes Management in Adult Primary Care Test Total Seen in Primary Care % Needing Mammogram 47,294 18,222 38% Needing A1c test 10,530 3,911 37% Approximately 60% of members seen in Specialty Care 24 12

13 Proactive Encounter - Obstetrics 25 Proactive Encounter - Post Partum Care 26 13

14 Proactive Inpatient Encounter (PIE) Pre Hospitalization/ Emergency Visits Admission/ Hospitalization Discharge/ Post Hospitalization Proactive Identification Identify needed labs, screening, medication management, etc. Document encounter in HealthConnect TM Provide member instructions Hospital Encounter Management Med reconciliation Assessment, vitals, advance care directive documentation Prepare patient for procedure, tests Activate patient in care: education, nutritional consult, social service, discharge planning Arrange DME, Home Health, Post Discharge Care Follow-up/Prevention Identify and provide immunizations Med reconciliation Discharge care instructions, schedule follow-up appointments, health ed materials Schedule screening appointments, KP.org information Post Discharge Call Transition Line 27 Spectrum of Care (i.e. ESRD, HF, HIV) (i.e. depression, diabetes, hypertension) (i.e. asthma, cancer screening) Model Created By Gail Lindsay R.N

15 Proactive Panel Management Healthcare team supports physicians to manage panel outside of face-to-face visit Local standardized process 1 2 Touches Unlicensed and licensed staff 29 Care/Case Management Ongoing local standardized process Focus on population-specific risks and care gaps 2 months or more Licensed staff 30 15

16 A centrally coordinated system Targets populations through batch mechanisms outside of the patient encounter (letters, e-letter, calls) Engage members in actions that improve health outcomes Accounts for over 10 million touches a year 31 ACE/ARB/Diuretics Lab Colorectal Cancer Screening FIT Kits and Live Reminder Calls Newborn Immunization Reminders Adolescent Immunization Reminders CVD Screening Lab Overdue Labs Reminder Asthma Adult and Pediatrics Introduction Asthma Adult and Pediatrics Diabetes Education Information Flu Information Pneumococcal Information Retinal Screening Blood Pressure Check Reminders Cervical Cancer Screening Reminder Mammography Screening Reminder Medication Adherence Reminder Vision/Glaucoma Screening Wild Fire Health Information Calls Chlamydia Screening Measles Call Adherence Calls 32 16

17 Online Personal Action Plan 34 Online Personal Action Plan The Online Personal Action Plan is a fully featured and integrated personal care gap monitoring system. Available in both English & Spanish, it explains clearly what is needed to take action on, why it is important and how to take the necessary action. The system monitors care gaps and automatically notifies the patient when a new gap arises. Available at kp.org and within 34 17

18 Cancer Screening a) Breast Cancer Screening (Mammogram) b) Cervical Cancer Screening (Pap Test) c) Colorectal Cancer Screening Preventive Care a) Body Mass Index (BMI) b) Tobacco Use Heart Health a) LDL Cholesterol b) Blood Pressure Immunizations a) Flu Shot b) Pneumococcal Chronic Health Conditions a) Diabetes (A1c Lab Test) b) Asthma General Clinical Guidelines Medication Adherence 35 Fasting Blood Sugar Section to target non-diabetic, nonpregnant members Recommendation for member to repeat test if FBS is too high Cancer Screening Update rules to match current guidelines (5 yrs. Vs. 3 yrs.) Addition of disclaimer for all nonhigh risk members Cardiovascular Risk New section under Heart Health Present the member FRS score to show risk Dynamic risk builder customized to member Recommend aspirin/statins conversation with provider for high risk Addition of kp.org resource links to help members understand heart health LDL Addition of an LDL graph to the detailed page Chronic Conditions - Asthma Addition of brand name Asthma medications to improve user friendliness. General Clinical Guidelines Addition of POLST/AD generic messaging Body Mass Index Display a friendly message to show optimum weight range in pounds Currently displays BMI alone Immunizations a) Flu Shot Logic updated to work off of the year, dynamically based on flu vaccine supply 36 18

19 A regional program that systematically identifies members who have inadvertent lapses in care Using a small, centralized team with limited clinical scope capacity to intervene before harm reaches the patient As well as several automated electronic tools, consistently used by accountable frontline staff, to track certain abnormal results for all members 38 19

20 Categories of Outpatient Safety Risk Diagnosis Detection and Follow Up Medication Safety 39 KPSC Regional Outpatient Safety Net: Current Portfolio Diagnosis Detection/ Follow Up Medication Safety PSA Electronic Safety Net +FIT Electronic Safety Net Abnormal Pap Electronic Safety Net Kidney Disease (Repeat Creatinine) Colon Cancer (Iron Deficiency Anemia + No colonoscopy) Colon Cancer (Rectal Bleeding+ No colonoscopy) Abdominal Aortic Aneurysm Tracking Post Splenectomy Immunizations Positive Chlamydia Follow up Down Syndrome Care Coordination Sickle Cell Care Coordination Hepatitis C (+Antibody + No confirmatory test ) Newborn Hearing Screening Lung Nodules Unintended Pregnancy Follow up Annual Lab Monitoring: Digoxin (K+, level and SCr), Diuretics (K+ and SCr) Amiodarone (Preventive monitoring plan) Acetaminophen Overuse Elderly Care Drug-Disease (Falls) Elderly Care Drug-Disease (Dementia) Elderly Care High Dose Digoxin Conversion Post-TAB Counseling Interacting Statin Combinations (Gemfibrozil / Birth Control and/or Amiodarone) Diuretic Medication Induced Hyponatremia Medication Induced Hyperkalemia NSAIDs in CKD 4-5, Dialysis, Kidney Transplant INH ALT monitoring Monitoring Plaquenil Eye Monitoring Metformin b12 monitoring Ethambutal eye monitoring 40 20

21 Adherence Reconciliation Safety 41 Clinical Information Systems Functions & Systems & Decision Support Appointment System Emergency Department Hospital Lab Membership Pharmacy KP HealthConnect Clinical Information Systems & Decision Support Registries (CDMS) Population Stratification Population Identification Patient Management Tools Immunization Tracking System Outpatient Encounter Systems Targeted Panel List Prompts & Reminders Monitoring Measures & Reports 42 21

22 44 guidelines developed to provide evidence based interventions CME created and developed to engage physicians and other members of the healthcare team may provide MOC credit provide education when needed 44 22

23 In Reach Proactive Encounter Care Management Outreach Panel/Care Management Reminder letter, e-letters, calls Colorectal Cancer Fit Kits/Live Calls Regional SureNet Online Personal Action Plan Virtual Total Health Assessment Healthy Living Helpline Coaching On-line Wellness and Chronic Condition Programs

24 Successful Practices Leadership and oversight Accountability and results reporting Staffing team sport utilize all human resources Close care gaps when patient present today s work today Team meetings and huddles Close the loop Coordinate and maximize outreach touches 47 For Information Kaiser Permanente SCAL SCPMG Michael Kanter, M.D. (626) Gail Lindsay R.N., M.A. (626)