Jim Bellows

Is patient activation associated with outcomes of care for adults with chronic conditions

We examined the patient activation measures (PAMs) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence, compared to patients with the lowest PAM scores. This population was 10 times more likely to report high patient-satisfaction scores, 5 times more likely to report high quality-of-life scores, and reported significantly higher physical and mental functional status scores, compared to those with the lowest scores. These results suggest that PAM scores are associated with key process and health outcome measures.

Patient Assessment of Chronic Illness Care (PACIC) and Improved Patient-centered Outcomes for Chronic Conditions

BackgroundThe Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral and quality measures for patients with chronic conditions.ObjectiveTo examine the relationship between PACIC scores and self-management behaviors, patient rating of their health care, and self-reported quality of life.DesignCross-sectional survey with a 61% response rate.ParticipantsIncluded in the survey were 4,108 adults with diabetes, chronic pain, heart failure, asthma, or coronary artery disease in the Kaiser Permanente Medical Care program across 7 regions nationally.MeasurementsThe PACIC was the main independent variable. Dependent variables included use of self-management resources, self-management behaviors such as regular exercise, self-reported adherence to medications, patient rating of their health care, and quality of life.ResultsPACIC scores were significantly, positively associated with all measures (odds ratio [ORs] ranging from 1.20 to 2.36) with the exception of self-reported medication adherence.ConclusionsUse of the PACIC, a practical, patient-level assessment of CCM implementation, could be an important tool for health systems and other stakeholders looking to improve the quality of chronic disease care.

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Objective:To understand factors leading to all-cause 30-day readmissions in a community hospital population. Research Design:Structured case series of 537 readmissions using chart reviews, interviews with treating physicians, patients and family caregivers, and overall case assessment by a nurse-physician team. Setting:Eighteen Kaiser Permanente Northern California hospitals. Results:Forty-seven percent (250) of readmissions were assessed as potentially preventable; 11% (55) were assessed as very or completely preventable; and 36% (195) as slightly or moderately preventable. On average, 8.7 factors contributed to each potentially preventable readmission. Factors were related to care during the index stay (in 143 cases, 57% of potentially preventable readmissions), the discharge process (168, 67%), and follow-up care (197, 79%). Missed opportunities to prevent readmissions were also related to quality improvement focus areas: transitions care planning and care coordination, clinical care, logistics of follow-up care, advance care planning and end-of-life care, and medication management. Conclusions:Multiple factors contributed to potentially preventable readmissions in an integrated health care system with low baseline readmission rates. Reducing all-cause 30-day readmissions may require a comprehensive approach addressing these areas. Future quality improvement efforts and research should identify existing and new tactics that can best prevent readmissions by addressing missed opportunities we identified.

Understanding panel management: a comparative study of an emerging approach to population care.

CONTEXT Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications have not been previously studied. OBJECTIVE To inform the ongoing spread of panel management by providing an early understanding of its impact on patients, physicians, and staff and to identify barriers and facilitators. DESIGN Qualitative studies at four sites, including patient focus groups, physician and staff interviews, and direct observation. FINDINGS Panel management allows primary care physicians to use dedicated time to direct proactive care for their patients, uses staff support to conduct outreach, and leverages new panel-based information technology tools. Patients reported appreciating the panel management outreach, although some also reported coordination issues. Two of four study sites seemed to provide a more coordinated patient experience of care; factors common to these sites included longer maturation of their panel management programs and a more circumscribed role for outreach staff. Some physicians reported tension in the approachs implementation: All believed that panel management improved care for their patients but many also expressed feeling that the approach added more tasks to their already busy days. Challenges yet to be fully addressed include providing program oversight to monitor for safe and reliable coordination of care and incorporation of self-management support. CONCLUSION Subsequent spread of panel management should be informed by these lessons and findings from early adopters and should include continued monitoring of the impact of this rapidly developing approach on quality, patient satisfaction, primary care sustainability, and cost.

Coordination of Diabetes Care in Four Delivery Models Using an Electronic Health Record

Background:Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely—and under what conditions—is not well understood. Objectives:To identify processes by which providers worked together to provide care using an EHR and to examine factors supporting coordination of care. Design:Qualitative multiple case study in 4 sites with diverse care delivery models, using semi-structured in-person interviews with 46 physicians and staff and telephone interviews with 65 adult patients with diabetes. Setting:Four Kaiser Permanente medical centers. Results:Across all care models, physicians and staff acted sequentially as loosely coupled links in a chain, relying on EHR-enabled informational continuity to coordinate care. Of providers, 94% were highly satisfied with the availability of patient information, and 89% of patients were satisfied or very satisfied with the coordination of their care. However, 6 of 65 patients described experiences of uncoordinated care, and 5 of 12 primary care providers identified coordination issues. These pertained to unreconciled differences of opinion, conflicting role expectations, and discipline-specific views of patient needs. Conclusions:Diabetes care can be coordinated across providers, but some coordination issues persist despite the informational continuity provided by an EHR. Multidisciplinary care teams should be alert to potential coordination challenges, and possible solutions should be explored, including longitudinal care planning with structured communications at key points in care.

Complete Care at Kaiser Permanente: Transforming Chronic and Preventive Care

BACKGROUND In 2004 Kaiser Permanente Southern California (KPSC) recognized the potential to improve the quality of care. Healthcare Effectiveness Data and Information Set (HEDIS) performance was below what regional leadership aspired to achieve, exceeding the 90th national percentile on only 15 of 34 measures. Beginning in 2005 regional leadership identified several system opportunities to enhance evidence-based, person-focused care. DEVELOPMENT OF COMPLETE CARE: KPSC developed and implemented a comprehensive delivery system redesign and expanded and integrated existing clinical information systems, decision support, work flows, and self-management support-collectively referred to as Complete Care. The goal of Complete Care is to transform care for healthy members, those with chronic conditions, and those with multiple comorbidities. To date, KPSC has applied Complete Care to 26 chronic conditions and areas of preventive and wellness care. Implemented in all care settings and optimizing the roles of all health care team members to maximal scope of practice, Complete Care provides evidence-based, person-focused care addressing a large set of protocol-based health needs for every individual during every encounter within the health care system. RESULTS On 51 HEDIS metrics, KPSC improvement using Complete Care averaged 13.0%, compared with 5.5% improvement in the national HEDIS 50th percentile. CONCLUSION Implementation of Complete Care at KPSC was followed by six-year quality gains that outpaced changes in the HEDIS national percentiles for many measures. Additional care gaps have been included in proactive office encounter checklists; these relate to elder care, advance directives, posthospital care, immunizations, health maintenance, and pregnancy care.

How Kaiser Permanente Uses Video Ethnography Of Patients For Quality Improvement, Such As In Shaping Better Care Transitions

Keeping patients and caregivers at the center of quality improvement is critical. Kaiser Permanentes Care Management Institute adapted video ethnography to achieve this aim, using video to capture interviews with-and observations of-patients and caregivers, identify patient-centered improvement opportunities, and communicate them effectively to clinical and administrative leaders and front-line staff. This method is particularly effective for helping understand the needs of frail elders, patients nearing the end of life, those with multiple chronic conditions, and other vulnerable people who are not well represented in focus groups and patient advisory councils. As part of an initiative to improve care transitions for elders with heart failure, video ethnography contributed to greatly reduced thirty-day hospital readmission rates, helping reduce readmissions at one medical center from 13.6 percent to 9 percent in six months. It also helped improve the reliability of the readmissions reduction program. When embedded within an established quality improvement framework, video ethnography can be an effective tool for innovating new solutions, improving existing processes, and spreading knowledge about how best to meet patient needs.

The Association between EHRs and Care Coordination Varies by Team Cohesion

OBJECTIVE To examine whether primary care team cohesion changes the association between using an integrated outpatient-inpatient electronic health record (EHR) and clinician-rated care coordination across delivery sites. STUDY DESIGN Self-administered surveys of primary care clinicians in a large integrated delivery system, collected in 2005 (N=565), 2006 (N=678), and 2008 (N=626) during the staggered implementation of an integrated EHR (2005-2010), including validated questions on team cohesion. Using multivariable regression, we examined the combined effect of EHR use and team cohesion on three dimensions of care coordination across delivery sites: access to timely and complete information, treatment agreement, and responsibility agreement. PRINCIPAL FINDINGS Among clinicians working in teams with higher cohesion, EHR use was associated with significant improvements in reported access to timely and complete information (53.5 percent with EHR vs. 37.6 percent without integrated-EHR), agreement on treatment goals (64.3 percent vs. 50.6 percent), and agreement on responsibilities (63.9 percent vs. 55.2 percent, all p<.05). We found no statistically significant association between use of the integrated-EHR and reported care coordination in less cohesive teams. CONCLUSION The association between EHR use and reported care coordination varied by level of team cohesion. EHRs may not improve care coordination in less cohesive teams.

A retrospective analysis of health systems in Denmark and Kaiser Permanente

BackgroundTo inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.MethodsRetrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability.ResultsA higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP

The next step towards making use meaningful: electronic information exchange and care coordination across clinicians and delivery sites.

1,951 (KP) and PPP