Telemedicine and a Vision for Health Care Without Walls

By | Guest Blogger, Uncategorized | One Comment

Post written by: Susan Dentzer, President and CEO, NEHI

Consider these real-world vignettes:

o A mother is in the midst of an emergency delivery of a baby at a small local hospital. But her baby is born safely because her doctor got real-time guidance by videoconference from an academic medical center more than a hundred miles away.

o A low-income patient in rural Virginia has severe and disfiguring psoriasis. But he can consult with a far-away dermatologist by video about the latest treatments to help restore his function and appearance.

o A cancer patient prepares to start treatment, but then learns via videoconference from an expert at a major cancer center that her cancer was inadvertently misdiagnosed by her local oncologist. As a result, she receives a corrected diagnosis and starts the appropriate regimen.

On one level, these anecdotes tell the story of telemedicine: The ability of patients, and often their local clinicians, to have consultations over distances with other clinical experts who can bring their insights to bear on patient care.

On another level, these stories herald far more: The unleashing of a system of “Health Care Without Walls” that can spread and democratize medical knowledge; meet patients where they are, in their homes, communities, or other locations; focus new attention on the social and economic circumstances in which patients live most of their lives; and defy the conventional boundaries of time and distance to get the right care to the right patient when it is most needed.

So, with all these formidable benefits going for it, why is telemedicine – a decades-old technology – only now beginning to make a dent in the delivery of health care in the United States?

This question and others were discussed at a forum I participated in, entitled “Leveraging Telehealth to Expand Access to High-Quality Care” and hosted by Kaiser Permanente’s Institute for Health Policy (IHP) at the Center for Total Health in Washington, D.C., on December 14. The forum brought together roughly 80 leaders from a variety of settings, including government, academia, advocacy groups, associations, think tanks, and health care providers to discuss the use of telehealth as an integral part of care delivery. Several themes emerged, including the potential impact of telehealth to improve access and quality, to help bend health care’s cost curve, and to address work force issues, such as perceived shortages of physicians. Challenges also surfaced, including the need to train and educate physicians, nurses, pharmacists and other care providers in caring for patients via telehealth; to address limitations on payment and reimbursement; and to fund further research to better understand telehealth’s promise.

As my organization, the Network for Excellence in Health Innovation (NEHI), has discovered in our Health Care Without Walls initiative, the reasons telemedicine is not yet playing a major role in U.S. health care are practically innumerable – and familiar to any serious student of our nation’s health care system and health policy.

A primary concern is cost. There’s no doubt that telemedicine, along with the gradual movement of care outside of hospitals and other conventional institutional settings, has the capacity to reduce costs in the broadest sense – not just to the health care system, but to patients and others. For example, an employee who doesn’t have to leave the work site to consult with a doctor, doing it instead via telemedicine, is an employee who won’t lose hours of productivity in the process. The University of Virginia Medical Center at Charlottesville, which offers telemedicine in 60 specialties and subspecialties, estimates that it has spared patients more than 17 million miles of driving to the medical center to obtain care.

But outside of capitated health systems such as Kaiser Permanente, where fee-for-service and volume-based payment still reigns, payers see telemedicine as a cost add-on. Too often, they say, a telemedicine visit results in a “punt,” where a doctor may interact with a patient via telemedicine then refer the patient for a follow-up visit to a primary care doctor or even send them to a hospital emergency room. The bill from the telemedicine provider is then simply an “extra” added to the overall tab.

Although all state Medicaid agencies now cover some form of telemedicine, similar concerns about payment add-ons have prevented Medicare from fully embracing telemedicine as well. With only a few exceptions, such as a telemedicine waiver available to participants in the Next Generation ACO model, Medicare mainly limits payment for telehealth to rural Health Professional Shortage areas and to services that extend from closely defined “originating sites,” such as physicians’ offices, hospitals, and skilled-nursing facilities.

Unless the entire U.S. health care system moves to full risk-bearing models, so that providers have real incentives to find more efficient modes of care delivery, it’s unlikely payers will change their tune. More payment models that will support telehealth adoption are needed within Medicare and commercial insurance. At NEHI, we’re working to develop proposals to pay for telemedicine as a means of transitioning providers along a kind of glide path toward great risk-bearing payment models.

Regulatory barriers to a greater role for telemedicine also abound. A number of states still bar clinicians from making diagnoses unless a patient is physically present in the physician’s office. And as far as practicing telemedicine across state lines is concerned, fewer than half of states have signed onto the Federation of State Medical Boards’ Interstate Medical Licensure Compact, which creates expedited pathways so physicians can apply for and receive licenses in states where they are not currently licensed – a prerequisite for conducting a lawful telemedicine session with a patient in another state.

These and other barriers – including health system inertia – must be addressed before telemedicine can reach its full potential. To spur a larger pro-adoption movement, however, it may be necessary to create a vision of future health care that supersedes any specific technology, whether telemedicine, remote monitoring, or even robotics. A true system of Health Care Without Walls could constitute more truly universal care that better united individuals, populations, and their care providers in direct pursuit of better health. Who among us could ask for more?

Fighting Hunger During the Holiday

By | Guest Blogger | No Comments

We know that “total health” is about more than absence of sickness, it’s about having a safe place to live, food to eat and nurturing, supportive relationships among other things. The holidays are always a great time to do what we can for our communities to support their total health. At the Center for Total Health, one community partner we wanted to call out this upcoming holiday is DC Central Kitchen. We offer a guest post from DC Central Kitchen’s Alex Moore below. Alex is featured in our Farmers Market display where we talk about food as a strategy for designing healthier communities. Keep his thoughts in mind as you think about giving back to the community this holiday season.

Happy holidays,

Keith Montgomery


Fighting Hunger During the Holiday Season

Alex Moore, Chief Development Officer at DC Central Kitchen

The holiday season is a time for giving back and helping others. At DC Central Kitchen, for example, we fight hunger by providing meals for our community each day while making longer-term investments in career training and job creation that strengthen local food systems and reduce disparities in health and economic opportunity, but we can’t do it alone! Here are some fun ways that you can help us and other food resource programs reach our goals:

  • Organize a turkey drive with your co-workers – Turn it into a friendly competition by making teams to see who can collect and/or donate the most turkeys! This will help provide the ultimate Thanksgiving meal for those in need.
  • Help plan a food drive through in your neighborhood or apartment building – By collecting staples such as beans, brown rice and canned goods, you can really food resource programs prepare daily meals on a large-scale.
  • Register to volunteer – Volunteers are needed daily – not just during the holidays to help prepare meals for our community 365 days a year.
  • Make a donation – If you are interested in making a financial contribution, check to see if there are matching donation programs to make you financial gift go further.

Whether you choose to support an organization like DC Central Kitchen or another important community organization, partnerships like the one with Kaiser Permanente’s Center for Total Health, help to highlight the many initiatives underway that are needed to address real problems in our community. I’m even featured in the Center’s farmers market display where you can hear me talk about my perspective on solving hunger, as well as the perspectives of others on food as a strategy for healthy communities. Check it out for yourself by visiting the Center for a tour!

About DC Kitchen:

DC Central Kitchen, located near Union Station in Washington D.C., is a nonprofit developer of innovative social ventures that break the cycle of hunger and poverty. Our mission is to use food as a tool to strengthen bodies, empower minds, and build communities. At DC Central Kitchen, we do more than just feed those in need. We run a 14-week culinary job training program to create economic stability for unemployed adults so they can leave hunger behind. Our social ventures provide 1.8 million meals for our community as well as healthy, locally-sourced meals to students at 15 low-income schools in DC.
If you would like to drop off items to DCCK, here are a few drop-off guidelines to follow, once you have successfully collected your items, you can drop them off during our regular hours, as follows:

  • Our regular hours for drop-offs are 8 a.m. – 4 p.m. on weekdays and 8 a.m. – 3 p.m. on weekends.
  • DC Central Kitchen’s physical address is 425 2nd St. NW, Washington, DC 20001. Please ensure that you receive a receipt for your donation from our on-site staff as we need to keep track of all food we receive. Donations are tax-deductible.
  • DC Central Kitchen is often able to pick up especially large donations. However, we greatly appreciate it if you are able to bring donations to our location. Please contact our food recovery team ( or 202-400-2804) in advance if you need to schedule a pick-up.


The dirty truth about receipts

By | Environmental health and safety, Guest Blogger, Uncategorized | No Comments

Guest blogger Joel Sigler is senior manager for Kaiser Permanente National Environmental, Health & Safety

The Center for Total Health has a self- service health assessment machine that provides visitors a printed receipt indicating their weight and body mass index (BMI). Recently, a visitor asked a great question about whether the receipt paper is coated with Bisphenol A (BPA).

BPA is an endocrine disrupter that mimics estrogen in the body. Studies have found that BPA exposure is potentially linked to a number of health concerns including breast cancer, diabetes, heart disease, sexual dysfunction, and obesity (kind of ironic if present in a machine that tells you your BMI). There are many sources of BPA exposure, it is found in many products including food can linings and plastic bottles. Unfortunately, receipt paper is one of the many items that can also potentially contain BPA. Receipt paper is of particular concern because it can easily be absorbed into the body when the receipt is handled. Absorption of BPA is sped up even more if hand sanitizer has been applied before handling a receipt.

We promptly called the manufacturer of the self-service health assessment machine to find out if they knew if the receipt paper contained BPA. The good news is that the manufacturer was very responsive. Within a day they had contacted their receipt paper supplier and verified that it was “BPA free.” They even provided KP a letter from the receipt paper supplier. Kaiser Permanente is continuing to communicate with them to find out about any BPA alternatives that they may be using. Bisphenol S (BPS) and Bisphenol F (BPF) are chemicals commonly used as substitutes for BPA. They are less studied than BPA and haven’t gotten the same attention. But because BPS and BPF are similar in chemical structure to BPA, experts have concern that they could represent similar health risks.

It is important to recognize that product manufacturers aren’t always this responsive. It often takes a lot of effort to get an answer to whether a product contains chemicals of concern, either because they don’t know, or because they don’t think it is important enough to find out. In this case, the question had gotten to the President of the manufacturing company and apparently he had gotten similar questions from other customers. So just asking the question helps drive action. It is unfortunate though that when it comes to chemicals of concern, the onus is on the customer/consumer (and not on manufacturers) to drive efforts to find out if a product is “safe.” Kaiser Permanente puts significant effort into identifying and eliminating chemicals of concern like BPA in the products that the organization purchases and uses.

The Environmental Working Group provides the following recommendations to reduce exposure to BPA from receipt paper:

-Minimize receipt collection by declining receipts at gas pumps, ATMs and other machines when possible.

-Store receipts separately in an envelope in a wallet or purse.

-Never give a child a receipt to hold or play with.

-After handling a receipt, wash hands before preparing and eating food (a universally recommended practice even for those who have not handled receipts).

-Do not use alcohol-based hand cleaners after handling receipts.

-Take advantage of store services that email or archive paperless purchase records.

-Do not recycle receipts and other thermal paper. BPA residues from receipts will contaminate recycled paper.

More information on all of Kaiser Permanente’s environmental stewardship program can be found at

First Mother’s Day Without Mom

By | Guest Blogger | No Comments

Patti Harvey, senior VP, Medicare Clinical Operations and Population Care, and executive director, Care Management Institute, has been a nurse for years, but nothing in her training prepared her for her role as her mother’s caregiver.

On Mother’s Day, I will be thinking about the enormous influence my mother had on my life and work.

Over the past 10 years, I have felt a strong personal connection to my work as a leader in care delivery at Kaiser Permanente. Even before then, my mom had joined KP as a member in 2002, after she and my dad moved to California to live with my family. My dad passed away in 2003 and my mom was a constant in our family for many years, providing care and comfort to all of us.

My mother passed away in November of 2015, so this will be my first Mother’s Day without her. She was not healthy for many years. She smoked cigarettes for almost 40 years and was plagued with almost every bad thing that smoking can do to a woman’s body, except cancer. I was her primary caregiver for 13 years, with help from all of my family.

I have been a nurse for many years, but my role as a caregiver for my mom was one that nursing school and graduate school did not prepare me for. My mom’s needs were complicated and she required support at home during the day while we were off working and going to school. We learned that caregiving for a loved one can create a physical, emotional, and financial burden for the entire family. Our KP members and employees have these same challenges.

My children learned to give insulin and breathing treatments. Walkers, wheelchairs, oxygen, many medications, and frequent trips to the doctor and hospital were a routine part of our lives. These were the physical things, but my mom made each one of us feel special and kept us smiling and enjoying her Texas humor. She told us what she wanted and needed and we worked to make it possible.

Her doctors and nurses knew her and she was a part of their family. Her primary doctor and I are good friends, and KP nurses at the Thousand Oaks clinic have my cell phone number. Her doctor was my support, too. We cried and laughed together trying to keep my mom strong. When it came time for him to have conversations about how my mom wanted to be cared for in her final days, he could not bring himself to talk to my mom about dying. He loved her and wanted to help in any way he could. My mom and I had conversations about what she wanted if she couldn’t make her wishes known. We completed her advanced directives and medical power of attorney.

Still, she had a lot to live for and she set goals for herself. She wanted to see my daughter graduate from college, she wanted to see my middle son graduate from college and pursue his love of flying, and she so wanted to see my baby boy graduate from high school. I am so thankful that she was able to accomplish these things in her life.

My mom fell and broke her leg and her health and well-being deteriorated rapidly. She was in the hospital and had gone through so many painful procedures, she couldn’t eat or sleep. She finally said she didn’t want to do this anymore and asked me to get her doctors to come to her bedside.

Later that afternoon, her hospitalist, her surgeon, her case manager, the nurse executive, her nurse, and I had one of the most powerful conversations of my life. My mom asked us to sit at her bedside and she began to tell us her wishes. Her doctors were both women and my mom said, “I am going to talk to you like I talk to my daughter because I have grown to love all of you. I want some tomato soup, I want to sleep until I wake up, I want to leave the hospital and go somewhere that has flowers and good smells. I don’t want any more pokes, tests, and pain. I want to go home.”

This conversation left us all in tears. Her hospitalist asked my mom, “Mary, what end-of-life care would you like?” My mom looked at me and said, “What the heck did she say?” I asked her doctor to rephrase the question: “Mary, what does a good day look like to you?” When her doctor asked her that question, her eyes sparkled, her voice lifted, she smiled and told us all stories of what a good day for her is. Later that day, her surgeon brought her some homemade tomato soup and ice cream.

My mom passed away five days later with my baby boy and me by her side. My grandson was born two weeks after my mom passed. She is his guardian angel and we will tell him stories of his angel “Nanny” and how she is with him.

I am sharing my story for two reasons. One is to remind me and those I get to touch that we have an opportunity to make the lives of those we serve better and to support their well-being throughout all stages of life. To do that we must listen and respond. The second reason is to help others understand the power of the voice, presence, and partnership of our patients and their families. Without listening and responding to my mom’s wishes, she wouldn’t have had her last good days.

Now to end this chapter in my story, I am a “granny.” Every day I try to make my grandson’s life better; and at work, I try to make our patients, their families, and my colleagues lives’ better — by listening, responding, and ensuring that we don’t lose sight of what we are blessed to get to do each day.

Happy Mother’s Day, Mom! Thank you for all you give me and us every day.

CEO Roundtable Policy Summit 2016

By | Care Delivery, Center for Total Health, Guest Blogger, Uncategorized | No Comments


On April 29, the Kaiser Permanente Center for Total Health hosted a policy summit convened by the American Heart Association’s CEO Roundtable. The CEO Roundtable represents 26 CEOs, including Bernard J. Tyson, from some of America’s largest corporations and organizations that have joined together to create and sustain a culture of health and well-being in the workplace by collaborating on best practices and measurable new strategies for employee engagement. Together through the AHA’s CEO Roundtable, these CEOs are leading by example to collectively engage their nearly eight million employees and family members, along with countless other community members, to improve health by making simple behavior changes that produce significant results.

Attendees at the CEO Roundtable Policy Summit


While many companies offer workplace health programs, program quality and outcomes data vary, so there are unanswered questions about the most cost-effective strategies to improve employee health and well-being. Technological advances in “big data” are opening new frontiers in generating deeper insights about what works and why. That’s why the CEO Roundtable was developed as a leadership collaborative dedicated to evidence-based approaches to workplace health and employee engagement.

The policy summit focused on issues critical to improving the health of our Nation’s workforce. Discussion included the policy implication of current wellness related tax issues and legislation, effective incentive design, the role of workplace culture and leadership, developing and promoting best practices for data privacy.

The summit included national thought leaders Judith Feder and Kevin Hassett to discuss policy and the political landscape for employer sponsored healthcare for 2016 and beyond. Judith Feder is an Urban Institute fellow, a professor of public policy and, from 1999 to 2008, was dean of what is now the McCourt School of Public Policy at Georgetown University. A nationally recognized leader in health policy, she has made her mark on the nation’s health insurance system through both scholarship and public service. Kevin Hassett is the State Farm James Q. Wilson Chair in American Politics and Culture at the American Enterprise Institute (AEI). Before joining AEI, Hassett was a senior economist at the Board of Governors of the Federal Reserve System and an associate professor of economics and finance at Columbia (University) Business School. He served as a policy consultant to the US Department of the Treasury during the George H. W. Bush and Bill Clinton administrations.

Shane Doucet, Principal from Williams and Jensen, moderated the day’s conversation. Over the last 15 years, Shane has represented clients in a variety of areas including health care, public pensions, law enforcement, and high-tech. Shane has also moderated panels comprised of top union, business and trade association representatives on the impact of health reform and has been a featured speaker for over 250 CFOs on health and wellness provisions of the Affordable Care Act.

For more information on the American Heart Association’s workplace health solutions, visit

Paving the Way to Active, Sensored Streets: Part 2

By | Guest Blogger, Uncategorized | No Comments

Our guest blogger this week is Sam Piper, Senior Planner, Alta Planning + Design. Alta Planning + Design designs and implements bicycle and pedestrian infrastructure for cities and institutions. This is part 2 of his blog. Click here to read Part 1. 

The streets of the future in the United states will be active, sensored streets, and will include dedicated infrastructure that makes travel by all modes of transportation comfortable. New technologies are paving the way to better understand mobility in urban contexts so that investments can be made where they are needed most. 

There are a number of current and emerging technologies that can capture and process non-motorized data efficiently and economically. After researching several of these technologies, Alta Planning + Design, a company that designs and implements bicycle and pedestrian infrastructure for cities and institutions, is excited to announce the publication of the Innovation in Bicycle and Pedestrian Counts white paper. This paper outlines the challenges that many communities face with conventional pen and paper count programs. It then identifies many new technologies that can automate, simplify, and expedite the collection of bicycle and pedestrian data.

Through Alta’s research, it became evident that new technologies generally fall into three broad categories:

  • Mobile Technology: software that can be downloaded onto a mobile device.
  • Imagery: technology that uses sensors to capture bicycle and pedestrian movements
  • Low-cost hardware: stand-alone technologies that are deployed to capture non-motorized data.

The graphic below lists the range of technologies that were reviewed for the white paper. Together, these technologies can be leveraged to plan and implement active transportation infrastructure, such as new paths, sidewalks and bicycle facilities, where they are needed most. When connected systems of comfortable facilities are implemented, more people will choose to bike and walk for more trips, as has been seen in multiple North American cities that have prioritized the development of bicycling and walking infrastructure, and are beginning to reap health benefits from these choices.


National Healthcare Decisions Day: April 16

By | Blog & Bloggers, Guest Blogger | No Comments

In recognition of National Healthcare Decisions Day on April 16, Christina Kerby, a senior communications consultant with Kaiser Permanente’s Care Management Institute,  spoke with people who have recently participated in Life Care Planning along with their facilitators about why these conversations are important for them and their families.

 Janie’s Story

Janie is a Kaiser Permanente employee in Northern California

I came home five years ago and discovered that my husband had passed away. My husband and I had shared our desires with each other so since he is no longer with me I felt it very important to let my daughter know what I desired in terms of my health. My daughter and I received an email regarding the Advance Care Planning Class held here at Kaiser Permanente. I filled out the advance directive and am very confident that my daughter will follow it to the letter. Now that everything has been discussed and final arrangements have been put in place, it will help to make the process easier.

Advance Care Planning is the way to go so that my loved ones won’t be burdened wondering what to do and how to handle my final transition. I have expressed how they should handle everything. To have this document in place, and my mortuary fees paid in full makes me feel that I have taken a lot of unnecessary stress off of my family.

Meri’s Story

Meri is a senior consultant with the Care Management Institute and a Life Care Planning facilitator

 Advance care planning is an important part of wellness, and we see it as a preventive service, just like mammography screening. We offer life care planning workshops for our employees because we feel that all adults regardless of age can benefit from thinking about and discussing what their own health care decisions would be if they are unable to speak for themselves due to a serious and/or sudden health crisis. It’s never too early to start having these important conversations.

I remember Janie and her daughter from the workshop. Janie told us she is a “planner” type of a person. So it makes sense that she would want to plan the end of her life as well! Janie, by having these conversations with her daughter and family, will help them to be prepared and minimize potential uncertainty, guilt and possible conflict between loved ones when the time comes.

Facilitating these workshops brings me a sense of pride that we are helping KP employees begin to think about how they want to live at the end of their lives, and share their wishes with their loved ones. We encourage everyone to choose a health care agent who would speak for you if you become unable to communicate your wishes.

 Matt’s Story

Matt is a retired military veteran married to a Kaiser Permanente member in Colorado

My wife is starting to have some memory problems. We were in the Memory Clinic here in Colorado, and Kay (our social worker) asked if we would be interested in Life Care Planning, and we said yes. We both needed to update our wills and we considered a living will part of that. It was a very convenient time to go through this.

The process was a little awkward at first because of the types of questions you have to think about. What creature comforts do you want at the end of life? How long do you want to be kept alive if you’re incapacitated? My wife and I travel a lot. What happens if we’re both in an accident? With Kay’s background and experience she was able to lead us in how to think about and anticipate those things.

No one wants to think about dying or being incapacitated. But we’ve had other family members go through this and it helped us think about our own wishes. I had a grandfather live for 10 years after a stroke that left him partially paralyzed. We all took turns taking care of him, and it was a strain on the family. In my wife’s case, when her parents became ill one person handled all the decisions and everyone else felt left out. My wife and I talked about how she would want to be taken care of. I’m an only child, and with my wife’s deteriorating health and memory, I will need to find someone else to be my health care agent.

It’s something that’s hard to get people to think about, especially younger people. In our case we’re in our sixties and early 70’s, but it’s something that’s on our mind.

Kay’s Story

Kay is a Licensed Clinical Social Worker in the Kaiser Permanente Memory Clinic in Colorado and a First Steps Facilitator and Instructor for Life Care Planning

I worked in hospice for 8 and a half years as a social worker before coming to Kaiser Permanente. One of the things that I observed countless times in my career in hospice was the difference that having an advance directive in place made between a patient having a “good death,” or a very “difficult death.” If there was no directive in place, and/or if there had never been any end of life discussions between the patient and their family members, things could become intense. Families often felt like they had to “play God” and guess whether or not their loved one would want interventions such as feeding tubes, ventilators and other aggressive measures during times of crisis. It was really difficult on so many levels for everyone involved in that process.

I’m a huge advocate of advance directives. In our Memory Clinic, we get to provide a very unique service because many of the patients that we work with are on the brink of lacking capacity to complete their advance directive, and we are able to assist them with that process in a timely manner. That feels great from my end, and is a huge gift to their families, as well.”

For resources and information about Life Care Planning, visit

Community-Based Organizations Remain Integral to Reduce HIV/AIDS Disparities

By | Care Delivery, Center for Total Health, Guest Blogger, Uncategorized | No Comments


For World AIDS Day (Dec. 1, 2015), we offer this following post written by community practitioners, advocates, activists and researchers with the Kaiser Permanente Community-Based HIV Test and Treat Initiative. Through the initiative they have found that community-based organizations play a critical role in serving people living with HIV when they are able to link their medical care with social, economic and behavioral support services – the total health of an individual. 


In July 2015, the White House updated its National HIV/AIDS Strategy for the United States, with a vision to ensure that new infections are rare and all people living with HIV (PLWH) have equal and unfettered access to HIV clinical care. Central to achieving this vision for the country’s 1.2 million PLWH are recommendations for widespread linkage to and retention in comprehensive HIV care, support for HIV medical adherence, and achievement of viral suppression. Unfortunately, racial/ethnic disparities persist in linkage to care, retention in care, and viral suppression. Community-based organizations (CBOs), and particularly AIDS Service Organizations, may be better able to provide more tailored approaches to reach and support socially vulnerable and minority PLWH, but there is little guidance in the national strategy regarding how CBOs can support these goals.

For World AIDS Day 2015, we offer our recommendations for CBOs to achieve these National Strategy goals, as a collective of community practitioners, advocates, activists and researchers with the Kaiser Permanente (KP) Community Based HIV Test and Treat Initiative. The Kaiser Permanente HIV initiative began in 2013 and involves implementation and evaluation of innovative community-based and CBO-led interventions to increase linkage to and retention in HIV care among Black and Hispanic men who have sex with men (MSM) in Los Angeles, CA; African American women and transgender women in Oakland, CA; African Americans in the rural and suburban southeast; and people who use drugs and those recently released from prison in the New York metropolitan area. While outcome evaluation findings are not yet available, our collective experience over the past three years demonstrates the following findings to support more effective CBO interventions:


  1. Community-based organizations (CBOs) can play an instrumental role in reaching PLWH, but require strong relationships with clinics to support linkage to and retention in care.

CBOs connected to racial/ethnic minority or socially vulnerable groups (e.g., prison releases, MSM of color, transgender women) and holistic AIDS services may have better reach to PLWH within these communities, than may non-community-based HIV clinics. Through partnership with CBOs, clinics may extend their reach for linkage and retention in care. CBOs with in-house clinical services and those effectively partnered with clinics appear to be most successful in recruiting and retaining patients who have fallen out of care. Culturally and linguistically tailored services were uniformly identified as central to meeting the needs of these clients.


  1. CBOs can support more effective HIV care by helping clients understand and recall medications and information on clinical indicators, such as CD4 and viral load.

While clinical care and initiation of and adherence to antiretroviral therapy (ART) can improve quality and longevity of life, meaningful engagement in HIV care and treatment requires understanding and recall of medication regimens and clinical indicators of health. Many participants reached through this initiative reported recent receipt of CD4 counts and viral load but could not recall the numbers, impeding their use of this information as a means of tracking their health. Low health literacy was also a concern, with participants reporting difficulties reading their medication bottle labels or understanding when to take their medications. CBOs can support patients’ health literacy related to medications and reinforce strategies for recall and interpretation of health indicators following clinical care appointments.

  1. CBOs’ promotion of effective engagement in HIV care for socially vulnerable populations requires support for clients’ linkage to care for key comorbidities, as well.

Vulnerable PLWH commonly present with multiple comorbidities, including substance use and mental health issues, as well as chronic diseases increasingly faced by the nation’s aging HIV-positive population. Linking clients to clinical care broadly, not just HIV care, is critical and may better support more cost-effective funding streams to help sustain CBOs working with PLWH by extending these health support services to vulnerable populations regardless of HIV status.

  1. Life-stabilizing wraparound services and trauma-informed care are needed to support HIV care utilization and medical adherence given the social vulnerabilities faced by PLWH.

HIV care utilization can only be prioritized when their clients’ diverse range of non-medical social needs are simultaneously supported through wrap-around services, including transportation assistance, housing, food security, and group support. A disproportionate burden of abuse histories across the lifespan is also reported among populations served through this initiative, and trauma-informed care and social services have been identified as requirements to support broader HIV and other health care utilization.

  1. Social support as part of palliative care remains an important CBO service for PLWH.

Life-enhancing benefits of ART are not reflected in the health status of our most socially and medically vulnerable PLWH, some of whom learn of their HIV status when they are already at Stage 3 disease progression, rendering a need for complementary palliative care support well into the 3rd decade of the epidemic. Too often social support networks are inadequate for PLWH, and end of life social support from CBO representatives may offer the only non-clinical social support available to these clients. Training and support for CBO staff providing these services is vitally important to help sustain CBO continuity of care.

We offer these recommendations for CBOs to support their capacities to extend the reach of clinical care and link and retain racial/ethnic minority and socially vulnerable PLWH in care, as we believe that elimination of health disparities in care utilization, medical adherence and HIV-related life expectancy requires a community-centered approach best achieved via CBOs. We believe that engagement of CBOs in partnership with HIV clinical care can accelerate the progress of the National HIV Strategy and achieve the Strategy’s vision with regard to “unfettered access to high quality, life-extending care, free from stigma and discrimination.”


Kaiser Permanente, National Community Benefit, Oakland CA

Alexandra Caraballo, National Manager, Philanthropy

John Edmiston, National Manager, Community Engagement

Pamela Schwartz, MPH, Director Program Evaluation

Melissa Ramos, Evaluation Consultant


UC San Diego Center on Gender Equity and Health- UCSD GEH, San Diego CA

Anita Raj, PhD, Professor of Medicine and Global Public Health

Lianne Urada, PhD, Assistant Professor of Medicine and Global Public Health

Laramie Smith, PhD, Assistant Professor of Medicine and Global Public Health

Sankari Ayyaluru, Research Coordinator


John Wesley Community Health (JWCH) Institute, Los Angeles CA

Sergio Avina, Division Director

Christopher Hucks-Ortiz, MPH, Evaluation Specialist


Institute for Public Health Innovation (IPHI), Prince Georges County MD

Bradley Boekeloo, PhD, Evaluator, University of Maryland

Abby Charles, MPH, Senior Program Manager


Public Health Institute (PHI), Oakland CA

Tooru Nemoto, PhD, Research Program Director

Mariko Iwamoto, Project Director


The Fortune Society, Long Island City NY

Nilda Ricard, Director Drop in Center-Health Services, Fortune Society

Brendan O’Connell, MSW, Senior Program Analyst

Jahad Robinson, Transitional Specialist


North Jersey Community Research Initiative (NJCRI), Newark NJ

Corey Rosmarin-DeStefano, Director of Clinical Services

Sharif Hall, Data Coordinator

Liliane Windsor, PhD, MSW, Assistant Professor, The University of Illinois at Urbana-Champaign


ASK4Care/Duke University, North Carolina

Beth Stringfield, Project Coordinator

Sara LeGrand, PhD, Assistant Research Professor of Global Health


Women Organized to Respond to Life Threatening Diseases (WORLD), Oakland CA

Cynthia Carey-Grant, Executive Director

Stephanie Cornwell, MA, Program Services Director

Samantha Feld, MPH, Evaluation Data Manager, Cardea Services, Oakland CA




Delving into the Data of Diabetes – A Research Roundup

By | Care Delivery, Center for Total Health, Guest Blogger, Uncategorized | No Comments

By Muriel LaMois and Natalie Kish

The Centers for Disease Control and Prevention recognizes November as National Diabetes Month. It represents a time to increase awareness for and understanding of living with diabetes. Nationwide, nearly one out of 11 people has diabetes, and more than one-third of adults are pre-diabetic. Kaiser Permanente treats many of its members with these conditions, and researchers across the organization study diabetes-related health issues to determine how to better serve these individuals.

Stabilizing Trends in New Cases of Diabetes

Several Kaiser Permanente regions participated in a study published in January 2015 aimed at determining trends in new diabetes cases in 11 integrated health systems from 2006 through 2011. After analyzing the health records of approximately seven million newly diagnosed diabetic patients aged 20 and older, researchers found no statistically significant increase in the number of diabetes cases between 2006 and 2010 – with the exception of a small rise in cases in 2011. However, they found significant increases in diabetes cases for certain groups, including racial and ethnic minorities, older adults, males, and people with higher body mass indices. Despite the relatively stable overall rate of new cases, these results suggest that new cases of diabetes are appearing more often in certain populations than in others. Gregory Nichols, PhD, Senior Investigator with Kaiser Permanente’s Center for Health Research, led the study.

Regional Trends in Existing Cases of Diabetes: In Northern California Ethnic Disparities Reduced

Andrew Karter, PhD, and researchers from the Division of Research, conducted a study to evaluate ethnic differences in the severity of existing diabetes-related complications. Study participants included Kaiser Permanente Northern California members with diabetes who were at least 60 years old in 2010. The complications included: myocardial infarction, stroke, heart failure, amputation, end-stage renal disease, advanced diabetic eye disease, and hypoglycemic events. Among those who were studied, 32 percent of patients had at least one complication in the past two years, with eye disease and heart failure occurring most often. Karter and his team also found that certain ethnic groups were more likely to have diabetes-related complications. According to the research, Whites have the highest prevalence for most diabetes-related complications and Asians and Filipinos have the lowest prevalence. The differences in the prevalence of complications between ethnic minorities were modest. These results suggest Northern California is making progress toward reducing health disparities of diabetes-related complications among existing patients who already have diabetes.

Kaiser Permanente Southern California Improves Detection of Diabetes-Related Eye Disease

Diabetic retinopathy is the leading cause of blindness among adults in the United States. A project conducted in Kaiser Permanente’s Southern California medical centers sought to improve diagnostic accuracy of this condition by implementing a centralized reading center that assigned a single team of technicians to assess images for diabetic retinopathy for all of the region’s facilities. The center allowed for physicians to have more time for patients who needed to see them; specially trained technicians to provide more consistent and accurate readings; and photographers to get feedback that improved their images. Most importantly, it allowed more patients with diabetes to learn whether they have potentially sight-threatening retinopathy, and receive appropriate education and treatment. Recently the retinopathy center initiative received the David M. Lawrence Patient Safety Award in recognition of the project’s impact on improving the safety of care for patients and accelerating the rate and scope of patient-safety improvements at Kaiser Permanente.


The Quest for Quality Care: Informing Clinical Decisions in an Integrated Health Care System

By | Care Delivery, Guest Blogger | No Comments

horbergEver-expanding health care costs have led to increased scrutiny of treatments and a new emphasis on value. In response, providers are seeking to improve clinical decision making by considering various factors, such as the effectiveness of different interventions, side effects, and how patients want to live their lives. Bringing these variables together is an example of the intersection of comparative effectiveness research and shared decision making between clinicians and patients.

Comparative effectiveness research allows healthcare professionals to compare different drugs, technologies, and care processes to ensure that they are best serving patients. Kaiser Permanente’s integrated health system, serving 10.1 million people across the nation, is uniquely suited for this kind of research. Michael Horberg, MD, MAS, one of the organization’s leaders in this space, discussed why this is true.

Michael Horberg, MD, MAS is the Executive Director of Research for Kaiser Permanente’s Mid-Atlantic Permanente Medical Group and Mid-Atlantic Permanente Research Institute

What role does an integrated health system with shared decision making like KP play in comparative effectiveness research?

Our goal is to conduct comparative effectiveness research on established processes or technologies to improve patient care.

The key aspects of clinical decision making are the patients’ wants, needs, aspirations, and their life stage. Research can always be very biological—for example, Drug A lowered blood pressure more than Drug B, so Drug A is superior—that doesn’t consider other factors, such as how often Drug A has to be taken. Drug A may be successful under ideal circumstances, but it may not produce the same effect in real-life situations, and FDA’s approval of a drug and patients’ willingness to take the drug don’t always align.

What’s important is synthesizing information for patients. In a non-integrated system, there isn’t a systematic way to make the decision between Drug A and Drug B. There is also not a method to weigh this data. In small fee-for-service practices, the doctors’ decisions may be based on a small sample of patients or lobbying by drug companies. At KP, we can collect information from a large sample of patients without industry influence and make more well-informed decisions.

Many stakeholders believe that comparative effectiveness research will have a moderate to substantial impact on healthcare decision making in the next five years. Where do you see it by 2020?

Comparative effectiveness is going to be critical, especially as patients become more engaged in care and more drugs, technology, and care processes become available.

Because patients are the center of care, we will see more talk about how to bring them into the decision making process and into research. A lot of the questions research scientists think are very clear in our minds can be broadened by incorporating patients’ perspectives.

We will also start to see a lot of people and organizations talking about the effectiveness of different technologies and practices. For example, in pharmaceuticals, we will see more studies comparing generic medications and branded prescriptions, as well as comparing different branded drugs. As we observe just minor gradations of improvement of one product over a previous product, people will start asking about the significance and magnitude of the added benefit or if there is any extra value at all.

To learn more about comparative effectiveness research at KP, please see the pages for the Mid-Atlantic Permanente Research Institute and the Center for Effectiveness and Safety Research.