Medicare: Examining Care Coordination and Evolving Payment Structures

Designing a Better, Greener, More Sustainable Hospital

Interview with Robin Guenther, Architect and Expert in Sustainable Design

Robin Guenther doesn’t just design pretty hospitals. She designs spaces that resonate health and well-being from the ground up.

As the sustainable healthcare leader at global architecture and design firm Perkins+Will, Guenther understands that every aspect of health and sustainability needs to be considered in the design of hospitals and healing spaces. It’s not enough to build hospitals with the latest healthcare technology. Rather, we need to be considering all aspects of a hospital’s building design and how that design lends itself to healing people and healing the planet.

“There’s something ironic about physicians, nurses and caregivers working to keep people alive and healthy in buildings that feel dead and that are built of materials that contribute to disease,” explains Guenther. “We need to build healthcare facilities that inspire health, that are built with healthy materials, that use as little energy as possible and that connect us with our living environments.”

Guenther was one of the keynote speakers at the CleanMed conference in Portland, Ore. this year. The conference is held annually for hospital and business leaders working at the forefront of sustainable healthcare.

In this video, Guenther shares some of her insights on the current trends in sustainable healthcare design – from building low-energy and net-zero hospitals to designing for the impacts of a changing climate.

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.”

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.

How’s Your Gut?

With March being Colorectal Cancer Awareness Month, it’s a good time for each of us to pause and consider the health of our digestive system.

“All About Our Guts,” one of the most popular episodes in the Total Health Radio series, helps with that. Expert guest T.R. Levin, MD, a gastroenterologist with Kaiser Permanente in Northern California, covers all the topics you’re wondering about: Irritable Bowel Syndrome, the potential benefits of an anti-inflammatory diet, why fiber is so important — even colonoscopies (and how to help encourage the one you love to go ahead and have that procedure done).

Here is exclusive bonus content.

Still want more? Check out the episode’s official page. And you can hear Dr. Levin talk about the FIT test – a non-invasive screening for colorectal cancer you can do in the privacy of your own home – in this video.

International Efforts to Improve Quality and Efficiency in Health Care

Murray Ross, PhD, vice president, Kaiser Permanente's Institute for Health Policy

Murray Ross, PhD, vice president, Kaiser Permanente’s Institute for Health Policy

Health systems across the world share a common responsibility to improve care. Rising health care costs and a growing drive for better outcomes create a need to spend health care funds efficiently and in accordance with each country’s priorities.

A response to this urgent demand requires, first, an understanding of which technologies and interventions—drugs, devices, diagnostics, and health care services—increase the quality and value of health care and, second, knowledge of policy levers that could encourage health care systems to adopt such technologies.

Comparative Effectiveness Research (CER) and Health Technology Assessment (HTA) are important tools used in different ways by countries to achieve these goals.

With support from the Kaiser Permanente Institute for Health Policy and the National Institute for Health Care Management, AcademyHealth researchers have produced a new report, “Improving Quality and Efficiency in Health Care through Comparative Effectiveness Analyses: An International Perspective,” that explores these issues. The report describes how the United States and other high-income countries assess effectiveness of new drugs, devices, procedures, diagnostics, and health care services and coverage decisions based on these assessments. The report also provides an overview of HTA activities in Europe, Canada, and Australia and examines the new public investments in CER in the United States.

The report calls for further engagement by international researchers and stakeholders to promote mutual learning.  You can read the report here.

What You Should Know About the Flu — A Chat with the CDC’s Angela Campbell, MD

Flu season is here. And to help us prepare for what the season may bring, we were lucky enough to get a few minutes with Dr. Angela Campbell, a medical officer in the Center for Disease Control and Prevention’s Influenza Division.

To welcome Dr. Campbell to the blog, we started out with one of our favorite questions.

Angela Campbell, MD

Angela Campbell, MD

Q: In a few words, what does Total Health mean to you?

A: Total health means caring for myself physically, intellectually, and spiritually, and working to sustain and improve the health of others.

Q: How does influenza vaccination factor into that view?

A: To me, influenza vaccination is an important component of caring for my own physical health – it is something I choose for myself every year. I am also passionate about encouraging flu vaccination for those whom I love, for my patients, and for the U.S. public at large. Flu is a serious disease that can lead to hospitalization and sometimes death. Even healthy people can get very sick from the flu. Because every flu season is different, it’s important to do what you can every year to protect yourself and those around you – and the first and most important line of defense against the flu is getting a yearly flu vaccination. Flu vaccination can keep you from getting sick from flu and, by protecting yourself from flu by getting vaccinated; you’re also protecting the people around you who may be more vulnerable to complications from flu illness.

Q: What is NIVW?

A: NIVW stands for National Influenza Vaccination Week, which was December 7-13 this year. CDC established NIVW in 2005 to highlight the importance of continuing flu vaccination throughout the holiday season and beyond. Flu vaccination coverage estimates from past seasons have shown that flu vaccination typically drops near the end of November, so this is a time to stress the important reminder that as long as flu viruses are circulating, it’s not too late to get your flu vaccine.

Q: Really? Is it worth getting your flu vaccine in December or even after the New Year?

A: Yes! Flu activity most commonly peaks between December and February, but can continue as late as May, so it’s not too late to protect yourself as long as flu activity is ongoing. In fact, even unvaccinated people who have already gotten sick with flu this season can still benefit from getting vaccinated since the flu vaccine protects against three or four different flu viruses (depending on which flu vaccine you receive) that are expected to circulate each season.

 Q: Can flu be more serious for some people than others?

A: Yes. CDC recommends a yearly flu vaccine for everyone 6 months and older; however, vaccination is especially important for protecting those at high risk for serious flu complications, including young children, pregnant women, people with certain chronic health conditions like asthma, diabetes, or heart and lung disease, and people age 65 years and older. Pneumonia and bronchitis are examples of flu-related complications that can result in a hospital stay or sometimes even death. The flu can also make chronic health problems worse for those who have them. And since babies younger than 6 months are too young to get their own flu vaccine, parents, caregivers and others in the household should be vaccinated to help protect them. By getting vaccinated, you will be less likely to get the flu and, therefore, less likely to spread the flu to others in these vulnerable groups.

Q: Should children receive one or two doses of the flu vaccine? We’ve heard different things.

A: Children 6 months through 8 years of age who are getting vaccinated for the first time, as well as some who have been vaccinated previously, will need two doses. Your child’s doctor, nurse, or other health care professional can tell you if two doses are recommended for your child. If your child has not already received their first dose of vaccine, get your child vaccinated now. Children who only get one dose but need two doses can have reduced or no protection from a single dose of flu vaccine. If two doses are needed, begin the process as early as possible. The doses should be given at least 28 days apart and it usually takes about 2 weeks after the second dose is given for protection to begin.

Q: If you don’t have time to get to the doctor, will insurance work at other vaccination locations?

A: Since September 2010, new health insurance plans are required to cover recommended vaccines without co-pays or deductibles when provided by an in-network health care provider. For more information on the Health Insurance Marketplace, visit Many private health insurance plans also cover the cost of vaccines, but you should check with your insurance provider before going to the doctor. Flu vaccines are offered in many locations, including doctor’s offices, clinics, health departments, pharmacies and college health centers. They also are offered by many employers, and are even available in some schools. Another useful tool is the HealthMap Vaccine Finder to find the nearest location where you can get vaccinated.

Leadership Perspective: Prediabetes Tsunami — We Can’t Just Wait For It to Hit

Editor’s Note: This post is part of the “Leadership Perspectives” series on the Center for Total Health blog —  a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Trina Histon, PhD, senior principal consultant with the Kaiser Permanente Care Management Institute, who shares her thoughts on prediabetes.


Few would deny the burden diabetes places on those who suffer from it and their loved ones who support them as they manage this disease. Estimates suggest that Americans with diabetes spend about $6,000 out of pocket per year managing their disease, monies that could be put to other use if we had more comprehensive ways implemented nationwide to prevent diabetes.

Trina Histon, PhD

Trina Histon, PhD

Many liken the next wave of diabetes as a tsunami that will hit the United States and its citizens, so let’s play that analogy through. Recent weather patterns have shown how devastating tsunamis are in the world, so much so, that efforts have been put in place to create sophisticated warning systems. So should another tsunami strike, countries will have advance warning so they are able to evacuate low-lying coastal areas and get people to safety.

In the U.S., the screening equivalent of that warning system for diabetes is an a1C test and the ADA has established a range of 5.7-6.4 as placing the individual in the “prediabetes” range. There are other tests, such as fasting blood sugar, but more and more health care is moving away from fasting blood work as it’s hard for people to fast for long periods of time. So this a1C range is our early warning system, and like most systems, it’s not perfect. In the literature this year, a few articles that discuss diabetes care and BMI have called into question the value of addressing prediabetes. These critiques are valid and perform an important function in both advancing the science and dialogue of where we want to spend our precious health care dollars.

Preparing for a Disaster We Know is on the Horizon

Kaiser Permanente today has 600,000 members with diabetes. We have also developed a cohort of just under one million members with lab values in the prediabetes range. Rather than wait for perfect science on exactly who needs an intervention, we feel ethically that if someone has a risk we should inform them and partner with them to address that risk, should they choose. One of the complexities of determining prediabetes risk is the prediabetes range has varying origins. For example, an a1C of 5.8 does not necessarily mean you will convert to diabetes, but you are at higher risk, and clearly are showing early signs of beta cell damage. What we do see is those with an a1C of 6.0 and higher and with BMIs in the obese range are most likely to convert. We are looking at our own data to see how we can further subtype the prediabetes risk spectrum and then subtype the interventions.

The Powerful Effect of Lifestyle Changes

The good news is lifestyle is the first line of treatment. The original diabetes prevention program (DPP) and subsequent translation trials show that those who lost 5 to 7 percent of their weight and increased their activity to 150 minutes/week prevented or delayed diabetes in 58 percent of participants over a three-year period – and 52 percent over 10 years. For most people, that translates to a 12- to 15-pound reduction, more attainable than the 30-40 percent of weight people might like to lose as reported on consumer surveys.
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When it Comes to Health Care, What Matters Most to Consumers?

Introduction from Bernadette Loftus, MD

Introduction from Bernadette Loftus, MD

Anyone who has had to choose a health insurance plan knows how confusing the process can be, even with the help of a friendly human resources professional. For the millions of Americans purchasing their coverage through exchanges, the process can be even more daunting.

Many consumers struggle to determine which plan is going to provide the best value – the coverage they need at a price they can afford. Dozens of organizations and publications – from the National Committee for Quality Assurance (NCQA) to Consumer Reports – rate health care plans each year. Some of these rankings are meant for the average consumer, but many are for industry insiders – laden with clinical terminology and detailed beyond what most people want to know.

On October 28, the Mid-Atlantic Permanente Medical Group and the Center for Total Health hosted what we hope to be the first in a series of events examining how we can translate these often technical ratings into something more consumer-friendly and how best we can get those ratings into the hands of the consumers.

Helen Burstin, MD, MPH, FACP, from The National Quality Forum, and Margaret O’Kane, from NCQA, set the tone for the day, reminding us that the patient must be at the center of all the industry does – not just care delivery. We must seek to provide our patients with the information they want in a way that is meaningful and accessible for them, while remembering that health care is a personal experience and much of what matters most cannot be measured. Dr. Burstin reminded us: Not everything that counts can be counted; not everything that can be counted counts.

Consumer Voices Panel

Consumer Voices Panel

Kaiser Permanente’s own Bernadette Loftus moderated a panel to understand what counts for consumers. Doris Peter, PhD, of Consumer Reports, emphasized that people can handle data.

“Just look at ESPN,” she reminded the audience, daring them to find a website with more data collected.

Dr. Peter and her co-panelists, Tina Reed of the Washington Business Journal, and consumer Iris Molotsky, agreed that uniform, consumer friendly terminology is a key step to making quality ratings more accessible for consumers. Ms. Molotsky, the president of Dupont Circle Village, a neighborhood association in Washington, DC, emphasized that “even well-educated, well-read, well-traveled” members of her community are confused by the complexities of standard health care language.

This sentiment was echoed by the last panel of the day, featuring the chief health officers of the District of Columbia, Maryland, and Virginia, as they lead their populations and health departments in the second open enrollment on the exchanges.

Great connections were made during the Mad Tea Party

Great connections were made during the Mad Tea Party

Leadership Perspectives: Good Health Starts Where You Are

Editor’s Note: Today, we launch a recurring feature on the Center for Total Health Blog. “Leadership Perspectives” is a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Elisa Mendel, national vice president of HealthWorks & Product Innovation for Kaiser Permanente, who shares her thoughts on place-based health.


How much time would you guess you spend at work each year? Would you be surprised if I said it’s something like 2,000 hours?

Elisa Mendel, VP of HealthWorks & Product Innovation for Kaiser Permanente

Elisa Mendel, VP of HealthWorks & Product Innovation for Kaiser Permanente

Compare that to the time we spend with our doctor — maybe 15 minutes once or twice a year? That’s why place-based health is so important. At its core, good health starts with us — where we live, work, learn, and play.

That’s one of the reasons Kaiser Permanente partnered with leading national organizations to launch Thriving Schools. The idea is that schools are the hub of every community. Our work in schools focuses on four key areas: healthy eating, active living, school employee wellness, and a positive school environment. One of the active living programs is called Fire Up Your Feet. Fire Up Your Feet’s fall campaign launches October 1, and it encourages kids to walk to school with their parents, giving them much-needed exercise and some quality time together.

Another initiative I really love combines the childhood enthusiasm for play with the workplace. It’s called “Instant Recess.” A manager or wellness champion schedules time with their team —usually about 10 minutes. Everyone stops what they’re doing, and one of the team members leads the group in dancing and exercise. People are moving, getting their blood pumping, and laughing together. It’s had amazing results, because when you’re doing the chicken dance with your supervisor, suddenly things feel a little less stressful.

Kaiser Permanente piloted this in various work settings — call centers, IT, and even the ICU. One of the ICU patients heard the staff doing this Instant Recess every day on the floor and she was determined to get out of bed so she could be wheeled out to participate in the fun.

There’s no limit to the benefits of healthy living. It can lift spirits and deliver real business results. One study in the Journal of Occupational and Environmental Medicine showed that employees who ate healthy and exercised regularly were up to 27 percent less likely to be absent from work for health reasons.

Good health is becoming a national movement. Find your “healthy,” and start to share good health close to your home.

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