Kaiser Permanente Implementation Journey for Long Term Conditions Management

Transcription

1 Kaiser Permanente Implementation Journey for Long Term Conditions Management Joel D. Hyatt, MD Assistant Regional Medical Director Kaiser Permanente Southern California NHSScotland Event 2008 Better Health, Better Care 25 June 2008

2 The LTC Program Implementation Journey Kaiser Beginning 1998 NHS Scotland Beginning 2006 Today (2008) Today (2008) Kaiser Future State Scotland 2

3 Population Care Management Implementation Journey (KPSCal) Asthma Diabetes Heart Failure ElderCare HIV/AIDS End Stage Renal CMI launched PCM leaders group formed Chronic Care Model adopted POINT and CMSS launched KP Disease Management Exercise Smoking Cessation Influenza Cervical Ca Colon Cancer Weight Mgt (Adult) Weight Mgt (Ped) Breast Cancer Pain Mgt Healthy Bones HTN CKD CVD/CAD Depression Asthma Diabetes Heart Failure Geriatrics HIV/AIDS ESRD 2007 KP Complete Care 3

4 About Kaiser Permanente Largest US nonprofit health plan Founded 1945 Integrated health care delivery system 8 Regions Serving 9 States and the District of Columbia 8.4+ million members ~ $30 Billion annual Budget Over 12,000 Physicians and Over 130,000 Employees 30 Hospitals and Medical Centers, and 431 Medical Offices Large investments in Research and Information Technology All employees and their families are KP members 4

5 Kaiser Permanente Vision 5

6 Kaiser Permanente An Integrated Healthcare System Mission Kaiser Permanente exists to provide affordable, highquality health care services to improve the health of our members and the communities we serve. HEALTH PLAN MEMBERS Collaborative vs. Adversarial Relationships KAISER FOUNDATION HEALTH PLAN Shared Decisions Aligned Incentives KAISER FOUNDATION HOSPITALS Hospital System Southern California PERMANENTE MEDICAL GROUP Multi-specialty Group Practice 6

7 KP Southern California ,270,120 members in Los Angeles, Orange, Kern, Riverside, San Bernardino, San Diego, and western Ventura counties, and Coachella Valley Medical Center Areas with 11 KFH Hospitals + Psych Hospital 7 KFH Home Health and 5 Hospice Agencies + Pharmacies, Social Services, Urgent and Emergency Care Over 100 Kaiser Permanente owned and or operated Medical Office buildings Multi-Specialty Group Practice SCMPG is composed of 9,458 physicians representing all specialties (3,279 Partners, 1,370 associates, 1,690 Affiliates and 2,354 per diems) Bakersfield 5 Simi Valley 118Thousand Oaks Panorama City Pasadena 405 Los Angeles Pacific Ocean Lancaster Anaheim 5 15 San Diego Riverside 15 Victorville San Bernardino Palm Springs Medical center (hospital and medical office) Medical offices Other facilities Regional administrative offices

8 Organizational (and Accountability) Structure Regional KPSCal (~ NHS Scotland) Priorities/Goals/Targets Accountability (Leaders, Performance) Infrastructure (Care Model elements) Coordination/Facilitation Medical Service Area (~ NHS Territorial Boards) Medical Service Area (~ NHS Territorial Boards) Medical Service Area (~ NHS Territorial Boards) x Total of 13 MSAs Medical Offices (multispecialty) Medical Offices (multispecialty) Medical Offices (multispecialty) Medical Offices (multispecialty) Hospitals Urgent Care Home Health Health Education Emergency Pharmacies Hospice Mental Health/Chemical Dependency Facilities Hospitals Urgent Care Home Health Health Education Emergency Pharmacies Hospice Mental Health/Chemical Dependency Facilities Hospitals Urgent Care Home Health Health Education Emergency Pharmacies Hospice Mental Health/Chemical Dependency Facilities Hospitals Emergency Urgent Care Home Health Health Education Pharmacies Mental Health/Chemical Dependency Facilities Hospice 8

9 KP s Integrated Health Care Delivery System Connecting all the Dots Specialty Care Rehabilitation Facility Primary Care Skilled Nursing Facility Alignment and Coordination Home (member) Call Center/ Advice Nurse (Pt Centered) Laboratory Hospital Pharmacy Emergency Room Urgent Care Care/Case Management Health Education Adapted from: Hyatt JD, Benton RP, Derose SF, JCOM, April

10 what does it cost to care for your employees and their families* with chronic conditions? PREVALENCE AND COST BY CONDITION ABC Company at Kaiser Permanente- Measurement Period Ending March 31, 2006 Setting Priorities/Goals/Targets Started with Diabetes (+ Heart Failure/elderly, asthma) * Continuously enrolled members during measurement period. ** For maternity values, the methodology for data capture is based on DXCG hierarchical condition codes. Results are based on maternity patients without other conditions. DXCG data is currently not available for Hawaii membership; therefore, condition prevalence and corresponding costs may be understated for populations that include Hawaii membership. Due to significant changes in the specifications in 2005, data may not be comparable to previous years. 11

11 Early Processes Helped us learn an approach and get early successes Started with Diabetes (then Asthma, Heart Failure) Diabetes Care Management (Condition) Leaders (MDs and Project Manager) Diabetes Care Management (Condition) Committee, with Diabetes implementation leaders from all Facilities Facility Diabetes (Condition) Care Management Implementation Teams KPSC Population Care Management Steering Committee with Regional infrastructure support leaders/units. Adopted the Chronic Care Model (Wagner) KPSC Population Care Management Leaders Group, with facility PCM leaders, Regional condition leaders, and Regional infrastructure support leaders Infrastructure leaders/units: pharmacy, clinical analysis, health education, communications, information systems, primary care and specialty care leaders, administration leaders, etc. Population Care Information Support (PCIS) Group that developed our chronic disease management systems, decision support tools, outreach tools, and performance measurement and feedback (supported accountability) Each Condition team planned, designed and developed their own strategies and implementation, including outreach, inreach/decision-support, provider and staff training/education, evidence based guidelines, communications, metrics. Competition emerged between/among condition based efforts 13

12 Systems Approach to Managing Care Regional vs. Local Responsibilities Community Resources and Policies Complete Care Model Health System Organization of Health Care SELF-MANAGEMENT DELIVERY DECISION INFORMATION SUPPORT SYSTEM SUPPORT SYSTEMS DESIGN SUPPORT Informed Activated Patient Productive Interactions Prepared, Proactive Practice Team Clinical & Functional Outcomes Adapted from Wagner E, et al, Managed Care Quarterly, (3)

13 Transformation from Traditional to Proactive Care Reassure Diagnose General Referral SICKNESS CARE MODEL (Current Approach - Physician Centric) Review Labs Access Social/Other Services Review/Adjust Rx and Tx EPISODIC, REACTIVE Counsel re: Lifestyle Changes Routine Preventive Care Office visits 15 minutes Deal with Acute Attack of Disease Modify and/or Negotiate Care Plans Reinforce Positive Health Behaviors Talk with Family Complete Forms Review Care Plan Review History PLANNED, PROACTIVE New CARE MODEL: Patient- Centric Proactive Care Care Delivered by a Health Care Team Care Integrated across Time, Place, and Conditions Care Delivered through Group Appointments, Nurse Clinics, Telephone, Internet, , Remote Care Technology Self-Management Support is Integral to the Delivery System 15

14 Care Management Support Begins with Population Care Information Support (PCIS) Patient Registry and Concurrent Tracking System (Chronic Disease Management System/CDMS) 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) across the health care system Supports Automated Clinical Decision Support and Practice Tools Inreach (reminders, alerts) Outreach Panel Management Tools (PMT) Supports telephone management and documentation Performance measurement and Reporting Leadership accountability for measureable performance targets 16

15 Clinical Information Systems Support Pharmacy Labs Hospital Pharmacy Outpatient Appointment System Outpatient Encounter Systems Membership Emergency Department Immunization Tracking System Clinical Information Systems secure web-based dynamic database real time not claims-based * CDMS: Chronic Disease Management System Registries (CDMS*) Stratification Identification of subgroups needing care (POPULATIONS) Patient management tools (PANEL MGMT) Targeted panel lists Prompts, reminders for clinicians/patients (DECISION-SUPPORT) Letters and automated telephone OUTREACH to members Monitoring and process improvement measures and reports 17

16 Clinical Decision Support and Practice Tools Manual to Automated Make it Easy to Do the Right Thing Inreach (directed to any provider): Care Management Summary Sheets (CMSS) Medication Alerts (high-risk drugs/elderly) Best Practice Alerts (KPHC) Preventive Care Prompts Outreach: Automated Mailings Automated Telephonic Outreach Care or Case Managers Links to other systems: Lab system standing orders Automated Telephonic support Panel Reports and Feedback Reporting/Tracking Performance Case Management Systems Flags/Alerts/Protocols Self-Management Support Health education Member.kp.org website (MyHeathManager) Health reminders Secure messaging 18

17 CMSS Decision Support Evolution Prompts/Reminders To Do/Orders Started as a Fax just for Diabetes in Primary Care Expanded to other conditions (patient centric) More connected to legacy info systems Printed at any visit registration When printed, supports nurse actions via orders Now part of EMR to use at any encounter Being replaced by EMR functionality 19

18 Care Management: Web Registry/Tracking System - SCAL By Medical Center and Region with drill down to MD and Patient levels Lists Panel Management Performance Measurement & Feedback 20

19 Population Care Management History of Growth (KPSCal) Siloed approach not sustainable Asthma Diabetes Heart Failure ElderCare HIV/AIDS ESRD CAD Asthma Diabetes Heart Failure ElderCare HIV/AIDS ESRD Depression CAD Asthma Diabetes Heart Failure ElderCare HIV/AIDS ESRD CKD CVD Depression CAD Asthma Diabetes Heart Failure ElderCare HIV/AIDS ESRD HTN CKD CVD Depression CAD Asthma Diabetes Heart Failure Geriatrics HIV/AIDS ESRD Breast Cancer Pain Mgmt Healthy Bones HTN CKD CVD/CAD Depression Asthma Diabetes Heart Failure Geriatrics HIV/AIDS ESRD Cervical Cancer Colon Cancer Weight Mgt (Adult) Weight Mgt (Ped) Breast Cancer Pain Mgt Healthy Bones HTN CKD CVD/CAD Depression Asthma Diabetes Heart Failure Geriatrics HIV/AIDS ESRD CMI launched PCM leaders group formed POINT and CMSS launched Chronic Care Model adopted SCPMG expands budget for PCM PCM steering committees New SCPMG Leadership Shift to publicly reported measures KP HC Ambulatory rollout SCPMG expands budget for PCM Exercise Smoking Cessation Influenza Cervical Ca Colon Cancer Weight Mgt (Adult) Weight Mgt (Ped) Breast Cancer Pain Mgt Healthy Bones HTN CKD CVD/CAD Depression Asthma Diabetes Heart Failure Geriatrics HIV/AIDS ESRD 2007 KP Complete Care 23

20 Drivers for Repositioning of PCM to KP Complete Care Work is duplicated; resources are wasted both regionally and locally Clarifiy centralized vs. decentralized functions Performance could be better with a different system Implementation of good ideas is too slow. Reliability and quality of implementation need to be improved Create units responsible for care processes and support of operations Move from disease entities driving work to functions or processes driving work (i.e. outreach, self care, etc.) Leverage the Electronic Medical Record and Personal Health Record Our care model needs to focus even more around the primary care physician and his/her team + role of specialty care More integration Common understanding of organizational priorities. Priorities should drive our work. Less compartmental and more collaborative structure PCM unit will not drive work Shared organizational responsibility All need to contribute to the planning and implementation 24

21 Kaiser Permanente Complete Care KPSCal Approach More centralized coordination with implementation support Regional Outreach Proactive Encounter Population Care Information & Decision Support Populations Management Complete Care Infrastructure Self- Management & Health Education Proactive Panel Management Care/Case Management Pharmacy Operations *All based on evidence-based clinical practice guidelines 25

22 Complete Care Council Focus on collaborative execution/implementation Health Education Physician Education Nursing Administration Clinical Analysis Pharmacy Operations Clinical Consulting Chiefs Groups (Primary Care and Specialties) Pain Geriatrics Osteoporosis Behavioral Health Depression MD Leadership Communications Clinical Strategy and Operations Outreach Proactive Panel Management Proactive Encounter Care/Case Management Populations/conditions support Clinical Decision and Information Systems Support EMR and members.kp.org Technology and Guidelines Local Administration 26

23 Embed the Right Thing to Do into Every Point of Care: Integrated IT Systems Support Across the Integrated Continuum KP Complete Care Primary Care Reminder/Prompts Access to Registry Call Center/ Advice Nurse Scripts Protocols Hospital Treatment Protocols Standing Orders Specialty Care Reminder/Prompts Access to Registry Rehabilitation Facility Adapted from: Hyatt JD, Benton RP, Derose SF, JCOM, April 2002 Skilled Nursing Facility Member Centered Care Management Home Outreach Letters Telephone Outreach Health Lines Flu Shot Reminders Healthwise Handbook Member Web site Remote Monitoring Laboratory Automated Standing Orders Urgent Care Reminders/Prompts Pharmacy Protocols Alerts Counseling Emergency Room Standing Orders Protocols Care/Case Management Protocols Health Education 27

24 How Care Management (Complete Care) Differs at KP Our programs are pro-active in design, with active patient care registries, automated reminders The entire population at risk is included in program Opt-in or referral not required Our integrated delivery system facilitates care coordination, including shared (electronic) medical records Integrated systems support pooling of outcome information to evaluate effectiveness of care Team-based care model is intrinsic to our approach to primary care with collaborative specialist support; not an afterthought or add-on Better provider participation in treatment guidelines & program design; our MDs develop, implement, use them Patient involvement and education is better because it is supported by primary care team 5/10/2010 revised gli 10/02/

25 Lessons & Conclusions It is a Journey Vision, Goals, Objectives, Accountability Framework (Care Model; Systems Approach) The I s Have it: Integration Infrastructure (support) Interactions (relationships, collaboration, coordination) Information (for all) Improvement (continuous and flexible) Clear Leadership Messages 29

26 Are our messages as clear as they could be? 30

27 31

28 Attachments Performance Results 32

29 Kaiser Permanente Southern California HEDIS National Rank 2006 performance reported in 2007 COMMERCIAL MEASURES (<65) Antidepressant Medication Management KPSCAL National Rank 90 th Percentile Effective Acute Phase Treatment 85.55% % Effective Continuation Phase Treatment 67.39% % Breast Cancer Screening Age % % Comprehensive Diabetes Care Medical Attention for Nephropathy 92.94% % Controlling High Blood Pressure Total 73.97% % Persistence of Beta Blocker Treatment after a Heart Attack 84.89% % Chlamydia Screening Age % % Age % % Total 68.04% % 33

30 Kaiser Permanente Southern California HEDIS National Rank 2006 performance reported in 2007 MEDICARE MEASURES (65+) KPSCAL National Rank 90 th Percentile Comprehensive Diabetes Care HbA1C Control (>9%) 10.22% % Comprehensive Diabetes Care Medical Attention for Nephropathy 96.59% % Comprehensive Diabetes Care LDL-C Screening 94.89% % Antidepressant Medication Management Effective Acute Phase Treatment 90.50% % Effective Continuation Phase Treatment 73.71% % Breast Cancer Screening Age % % Total 88.72% % Osteoporosis Management for Women Who Had a Fracture 51.46% 1 32% 34

31 Kaiser Permanente Southern California CCHRI Statewide Rank 2006 performance reported in 2007 COMMERCIAL MEASURES (<65) KPSCAL Statewide Ranking Childhood immunization combo 2 86% 1 Childhood immunization Combo 3 82% 1 Adolescent immunization 74% 1 Appropriate use of meds for adults with asthma (age 18-56) 95% 1 Retinal exams for diabetics 76% 1 Nephropathy screening for diabetics 93% 1 Persistence of beta blocker after AMI 85% 1 Controlling high blood pressure 74% 1 Cholesterol screening for people with CVD 95% 1 Breast cancer screening ages % 1 Chlamydia screening age % 1 Chlamydia screening age % 1 Antidepressant management-optimal practitioner contacts 30% 1 Effective acute phase Rx of depression 86% 1 Effective continuation phase Rx of depression 67% 1 Inappropriate antibiotic Rx for acute bronchitis 31% 1 35

32 Kaiser Permanente Southern California CCHRI Statewide Rank 2006 performance reported in 2007 MEDICARE MEASURES KPSCAL Statewide Ranking A1c testing for diabetics 95% 1 A1c< 9% 90% 1 Retinal exams for diabetics 85% 1 LDL screening for diabetics 95% 1 Nephropathy monitoring for diabetics 97% 1 Persistence of beta blocker after AMI 87% 1 LDL < 100 mg/dl in patients with CVD 68% 1 Breast cancer screening ages % 1 Osteoporosis management after a fracture 51% 1 Antidepressant management-optimal practitioner contacts 17% 1 Effective acute phase Rx in depression 91% 1 Effective continuation phase Rx in depression 74% 1 Drugs to be avoided in the elderly (2 or more Rxs) 4% 1 36

33 KPSC Controlling Blood Pressure (HEDIS) Significant and Rapid Improvement 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% 74% 55% 55% 53% 56% 46% 25%

34 Low Cardiac Mortality After Acute Heart Attack (KP SCAL) 30-Day Mortality After Acute Heart Attack KPSCR Hospitals vs All Other Hospitals in Same Counties Day Mortality After Acute Heart Attack KP NCal hospitals vs. all other hospitals in counties with KP hospitals -11 of 11 KPSCR hospitals are below the state average of 12.1% -9 of 11 KPSCR hospitals are significantly better using a p value <0.05 and 4 of 11 at a more stringent level of p < of the10 hospitals with statistically significant lower rates (p<0.01) are KPSCR hospitals 20.0 KP The Rest 14% % 0.0 Source: State of CA OSHPD 38

35 Cancer Outcomes KP 5 Year Survival SEER 5 Year Survival Lives Saved Per Year Breast 92.3% 88.6% 107 Colon 72.9% 64% 132 Melanoma 97.9% 91% 76 39

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37 The ROI of Quality The ROI of Quality- The NCQA Quality Dividend Calculator Work Days Gained by Disease for Commercial Employed Population By Health Plan (2 Million Members) 41