Learning from Leading Performers to Improve Depression Outcomes

Editor’s Note: May is Mental Health Month, and Kaiser Permanente has joined forces with the National Council for Behavioral Health, Mental Health America, and other organizations across the country to help raise awareness around the importance of early identification of symptoms and reducing stigma around mental illness.  Guest blogger Christina Kerby spoke with several people from the Kaiser Permanente Care Management Institute for the following post.

Mental Health OutcomesWhen we think about cancer, heart disease, or diabetes, we begin with prevention. When people begin to show signs such as a persistent cough, high blood pressure, or high blood sugar, we try immediately to identify the problem and reverse these symptoms. We don’t ignore them. In fact, we develop a plan of action to reverse and sometimes stop the progression of the disease. So why aren’t we doing the same for individuals who are dealing with potentially serious mental illness?

Mental health conditions should be addressed long before they reach the most critical points in the disease process. One of the best ways to identify early symptoms is through routine use of tools in primary care settings that can aid in diagnosis and gauging effectiveness of treatment. One such tool is the Patient Health Questionnaire-9, or PHQ-9, a brief questionnaire that can be administered by any clinician as part of routine office visits or online via secure messaging.

The PHQ‐9 has been shown to be a useful tool not only for assessment and diagnosing, but also for monitoring treatment of major depression. To understand how this tool can be best used across the continuum of care, and how consistent use can improve depression control rates, we turned to our Seattle-based affiliate Group Health, which has experienced excellent results through its Depression Care Program.

To better understand Group Health’s success, we interviewed patients and care providers, collected and analyzed performance data, observed care settings, and pulled together the results in this case study.

“We found that Group Health consistently outperforms external benchmarks for six-month remission rates after a new diagnosis of depression,” said Andrew Bertagnolli, PhD, Senior Manager for Behavioral Health at Kaiser Permanente’s Care Management Institute.

Kaiser Permanente’s use of the PHQ-9 to assess symptom severity at the beginning of a depression episode has improved, helped by tools within our electronic medical record to enable easier administration and capture of the PHQ-9. The Northwest Region, in particular, has seen an improvement from 20% to 77% of members being assessed at the beginning of their episode.

“This is powerful data that shows the integration of behavioral health into primary care settings improves outcomes for patients by helping to identify symptoms early on,” said Dr. Bertagnolli.

In addition to improving assessment rates and outcomes, we can use Group Health’s performance to inform the way we spread and operationalize practices that improve care and outcomes for our members and patients. The case study examines how to generate will, change a culture, and support and sustain the practice. The case study is a rich resource for other organizations also wanting to learn from a leading performer in depression care.

“Kaiser Permanente’s integrated system enables us to spread leading practices quickly,” said Scott Young, MD, of the Permanente Federation. “This case study represents our commitment to learning and sharing for the benefit of providers and patients everywhere.”

Care at Home: Meeting Patients Where They Are

Care at home strategies seek to establish a win-win situation in which patient satisfaction goes up while use of health care services and spending go down. In some cases, seniors may be able to maintain their independence living at home longer, while reducing spending on nursing home care and hospitalizations. In other cases, the programs can help to avoid acute care episodes and readmissions.

To bring care to where patients are—and where they prefer to be—Kaiser Permanente Northwest has established an innovative program called Primary Care @ Home, and a ground-breaking pilot program called Mobile Health Partners (MHP). Primary Care @ Home originated as a pilot and is now an ongoing program. The MHP pilot has seen consistent growth since its inception in 2013.

These initiatives have showed positive results from patients and have demonstrated that home-based primary care can provide personalized care that maintains patient comfort and dignity, provides safe, high-quality care in a way that patients and families prefer, and lowers costs.

The Institute for Health Policy’s latest KP Policy Story highlights the two programs aimed at providing efficient care that best meets patients’ needs. You can check it out here.

Nurses

Thank You, Nurses!

 

There are more than 2.7 million nurses in the United States, working every day to treat and help patients in all corners of the country. This week (May 6 – May 15) is National Nurses Week. If you know a nurse, or see a nurse, take a minute to say thanks. We all know that nurses are critical members of the care team, but sometimes we forget to appreciate all they do. If you are a nurse, know that – even though we might not always say it – we appreciate all that you do for your patients, colleagues, and communities.

 

 

A Prescription for Activity

This week, the American College of Sports Medicine (ACSM) convened a meeting to address key issues related to establishing a physical activity prescription at every visit as a medical standard of care. Kaiser Permanante’s own Robert Sallis, MD, was in attendance and helped lead a walking break to visit the Supreme Court. You can find a full set of images from the roundtable here.

Dr. Bob Sallis leads a walking meeting to the Supreme Court.

Dr. Sallis leads a walking meeting to the Supreme Court.

There is overwhelming evidence on the health burden of a sedentary lifestyle, and regular exercise has been proven to prevent and treat a wide range of diseases.  For this reason, every health care provider should be assessing the physical activity habits of their patients and recommending they engage in 150 minutes per week of moderate exercise (like a brisk walk), which is consistent with the U.S. Physical Activity Guidelines.  While it has become a standard of care to ask patients at every visit about smoking and to assess their weight and BMI, exercise is often not routinely assessed.

For this reason, on April 27 and April 28, a roundtable was convened by the American College of Sports Medicine and Kaiser Permanente: A “Call to Action on Making Physical Activity Assessment and Prescription a Medical Standard of Care”.  This was held at the Kaiser Permanente Center for Total Health in Washington, DC, and it was chaired by Robert Sallis, MD, a Kaiser Permanante family physician and chair of the Exercise is Medicine Global Health initiative.  The meeting was attended by individuals representing a range of major medical organizations with a goal of developing a consensus around including physical activity assessment and prescription at each patient visit.  One of the outcomes of the roundtable will be a white paper that outlines a plan to make this happen in the near future.   

Four Years Flew By…

CTH team's most recent photo

CTH team’s most recent photo (2015)

Earlier this month, the Center for Total Health team celebrated its fourth birthday. Fittingly, this year the Center’s birthday (April 11) fell on a Saturday, so we each got to celebrate by exercising our own total health.

Five of the original Rosies visit the CTH

Six of the original Rosies visit the CTH (2014)

Four years is a long time, but also not long at all. The number and variety of people the Center has hosted and learned from in that time is absolutely staggering. We’ve had more than 7,500 visitors and hosted more than 600 events and tours. Those guests range from the Surgeon General to five original Rosies; from international health leaders to local students; from White House chefs to authors.

Each one of these guests and events has taught us so much – not just about health, but also about planning, flexibility, and new ways to use our space. With that knowledge, we will shortly begin the first significant renovations to the Center since it opened. On May 25, the doors will close for about three months and construction crews

One of many walking meetings led by CTH team (2013)

One of many walking meetings led by CTH team (2013)

will descend upon us. We will reopen in September, with new content and improved meeting space, but the same goal: sharing, developing, and accelerating ideas that improve total health around the world.

You can find four years worth of total health photos here. Special thanks to Ted Eytan, MD, for taking so many of them, and inspiring the rest of us to take more, too!

Busy Day at the Center for Total Health!

Thursday, April 16th, was another busy day for the Center for Total Health team, including four tours. We kicked off the morning with a group of regional health care leaders from Australia, then met a retired Kaiser Permanante nurse and information technology maven, a group of Robert Wood Johnson Foundation fellows, and Kaiser Permanante IT specialists from California. As always, we learned as much (if not more) from our visitors as they did from us.

PricewaterhouseCoopers Australian Delegation

PricewaterhouseCoopers Australian Delegation

For National Healthcare Decisions Day, a Conversation with Daniel Johnson, MD, FAAHPM, on Planning for Your Care

The Denver Hospice.   (Photo by ELLEN JASKOL)In recognition of National Healthcare Decisions Day on April 16, we spoke with Dr. Dan Johnson, national physician lead for palliative care at Kaiser Permanente’s Care Management Institute, to demystify health care decision making and understand the importance of advance care planning.

Q: What is advance care planning and why is it so important?

A: Advance care planning (ACP) is the process of planning for future medical decisions. ACP enables you to better inform and direct your care in situations where you’re not able to speak for yourself. Importantly, ACP:

  • starts with reflection and conversation around personal values, goals, and beliefs;
  • includes others – loved ones, family members and your health care team; and
  • often results in completion of an advance directive – a written plan for future medical care regarding goals of care or desired treatments for a possible or probable event.

It’s not easy to think about serious illness, much less plan for it. Yet we must. Advance care plans protect us when we cannot speak for ourselves. It’s a precious gift to our loved ones. Instead of guessing, our families and doctors have much needed guidance to ensure the right care.

Q: Why do I need to do this, especially if I’m healthy?

A: Accidents and serious illness sometimes strike suddenly. Terri Schiavo never planned for a cardiac arrest at age 26. Without prior plans or an appointed decision maker, her health care team and family were left to guess her wishes around prolonged life support. Sadly, the guessing irreparably divided her family.

Not everyone is ready to fill out an advance directive. Having a conversation with your health care team is still helpful in these instances to communicate the things that matter most to you. Appointing an agent – someone to speak for you if you cannot speak for yourself – is a crucial step at any time, even when you’re not fully sure of your wishes for future care.

Q: I already filled out an advance directive. Do I need to do this again?

A: Possibly. This question is best answered by your doctor and health care team. For example, sometimes documents filled out in one state are not valid in all states. Documents completed in the absence of informed discussions are rarely helpful (and often confusing). I would recommend re-doing your advance directives if you know your plans have changed or if you did not include your loved ones in your original planning discussions.

Q: Do I need to use any specific forms for an advance directive — from a particular care provider, for example?

A: No.  For instance, many Kaiser Permanente regions are beginning to offer our members advance care planning classes or one-on-one facilitated sessions — but no one is required to use a Kaiser Permanente advance directive form. Talk with your doctor and health care team to learn about your options.

Anyone can use Kaiser Permanente forms. Regardless of the form you use, be sure to discuss your values, preferences and documents with your health care team.

Q: How can I be reassured that the health care provider will look at my advance directive and follow my wishes?

I’d recommend two things. First, insist on including your health care team in discussions. Your physician and other providers will help you ask the right questions, explore your values, and pose important “what ifs” to help you communicate treatment preferences. The team will help you complete a written directive and assure that directive is correctly stored in your medical record. Second, include your loved ones. Ensure your appointed “agent” is present during actual conversations and completion of directives. Give copies of completed directives to your doctor, agent and other loved ones so that those who are most important to you know your wishes.

A: What happens if I want to update my advance directive? Do I need to fill out a new one?

Remember, advance care planning is not a single event. Rather, it is a series of conversations that start when we’re healthy and continue throughout our lives. Yes, refresh your discussions and directives with major changes in your relationships, personal values or health status. Your doctors (in concert with your appointed health care agent) will always use the most recently completed documents to direct your care.

To learn more, check out this article on the Kaiser Permanente Share site, or find additional resources available from NHDD.

Leading Transformative Change in Medicine: Highlights from the 2015 Lown Conference

Lown“There’s a thread you follow. It goes among things that change. But it doesn’t change…” reads first line from the poem The Way It Is, by William Stafford, which was recited by panelist David Hirsh, MD, at the 2015 Lown Annual Conference.  Medical students, he explained, are often surprised by the breadth and depth of the unique challenges they encounter in the U.S health care system. Holding on to their ‘thread’ is a reminder to focus on the human compassion that led them to the field in the first place.

The notion that physicians of all stages in their careers are a critical part of transforming the health care system represented a key theme of the conference, which focused on advancing change through grass roots movements in communities and health care settings. Patient advocates also told personal stories of how their lives were affected by a culture of inappropriate use in medicine coupled with unjustified prices for health care services.   Other themes included a renewed focus on primary care, overcoming the ‘more is better’ approach to medicine, and bringing dignity and choice to decision making around end-of-life care.

Titled, “Road to RightCare: Engage, Organize, Transform,” the conference was held March 9 through 11 in San Diego, California, and co-funded by Kaiser Permanente.  It brought together clinicians, researchers, advocates, patients, and community leaders, many of whom were members of the RightCare Alliance, an organization devoted to reducing overuse, underuse, and misuse of medical tests and treatments while restoring  the trusted clinician-patient relationship.  United States health care spending is expected to exceed $3 trillion in 2014, with inappropriate use accounting for as much as $1 trillion of that spending.  Addressing this crisis is fundamental to achieving the goal of delivering compassionate medicine that benefits both people and their communities.

For more details about the conference, check out this longer post on the Kaiser Permanente Institute for Health Policy website.

An Uncomfortable Truth: Screening for Colorectal Cancer Can Prevent a Deadly Disease

March is coming to a close, and with it, Colorectal Cancer Awareness Month. But when the clock strikes midnight on the 31st, we shouldn’t lose sight of the devastation that colorectal cancer can cause. A new story from the Kaiser Permanente Institute for Health Policy explores Kaiser Permanente’s journey towards improving screening rates, and outlines what it will take for the nation to do the same.

Colorectal cancer is the third most common cancer in America and the second leading cause of cancer-related deaths, with an estimated 49,700 Americans who may lose their lives to the disease in 2015. The good news is that it is highly treatable if caught early; up to 80 percent of deaths can be prevented if everyone over 50 receives a recommended screening. The bad news is that many people — about a third of all Americans and even more in certain racial or ethnic groups, such as Latinos — still aren’t getting screened.

Over the past 10 years, Kaiser Permanente has been leading the charge to improve colorectal cancer screening rates and reduce deaths due to the disease. By reminding people to get screened at every point of care, improving access to the Fecal Immunochemical Test (an easy, home-based colorectal cancer test) and focusing on disparities, Kaiser Permanente has nearly doubled screening rates — from 43 percent in 2004 to 82 percent in 2013.

If you are over 50 or at risk of colorectal cancer, please remember to get screened. And check out the Institute for Health Policy story for more information.

Green is the New Gold Standard for Total Health

Solar Panels, Kaiser Permanante Santa Clara

Solar Panels, Kaiser Permanante Santa Clara

Environmental health and the health of individuals and communities are strongly connected. As a health care provider, Kaiser Permanente feels a special responsibility to address the impacts of climate change on health and to reduce pollutants that can lead to disease. It’s all part of how we look at the total health of people and communities, considering all of the factors that influence their health outside of the doctor’s office.

That definition for total health became richer with the recent announcement that Kaiser Permanente was joining the august ranks of Apple, Google, and other large, environmentally-conscious companies that choose to be leaders in the green energy arena.

KP_SustainableEnergy_BrochureKaiser Permanente announced last month that we completed several agreements to purchase enough renewable energy to reduce our greenhouse gas emissions by 30 percent nationwide by the beginning of 2017. These agreements mean that about 50 percent of the electricity used at our facilities in California will come from renewable energy sources.

The health care sector is poised, perhaps better than most, to plug in to the conversation about the health impacts of climate change and help direct the next stages of climate action. The health care industry carries a considerable environmental footprint, and Kaiser Permanente is partnering with Health Care Without Harm and the Business Renewables Center, launched recently by nonprofit Rocky Mountain Institute, to help not only the health care industry, but the entire U.S. business sector, move toward more abundant clean energy solutions.

“Climate change isn’t a distant threat,” said Kathy Gerwig, Kaiser Permanente’s environmental stewardship
officer. “The health impacts of a changing climate can be felt today in the form of increasing rates of asthma and other respiratory ailments, spread of infectious diseases, heat stress, and injuries from severe weather events. By addressing climate change for the future, we are improving the health of communities today.”

Purchasing renewable energy supports KP’s core mission of total health, and it also makes good business sense.

“We expect this energy purchase to be cost neutral over the term of the contracts,” said Ramé Hemstreet, Kaiser Permanente’s chief energy officer. “By locking in rates, we can better forecast energy costs, and by using diverse fuel sources, we can protect our business from escalating and volatile energy prices. That’s great news for our members.”

So, the next time you see or visit a Kaiser Permanente facility, rest assured that green energy is making a major contribution to powering our facilities, addressing climate change and improving the total health of our members and communities.

More details of this announcement are captured in the infographic, video, and press release on Kaiser Permanente’s Share website.

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