The Future of Care Delivery

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You walk in, verify at a kiosk that you’ve already checked in and paid, plug in your laptop at the charging station, and soon get a text that it’s your turn. No — you’re not at Starbucks — you’re at Kaiser Permanente’s new Signal Hill Medical Office in Southern California for your medical appointment.

Signal HillSignal Hill exemplifies Kaiser Permanente’s most recent effort of evolving its care model to better integrate into members’ lives.

“Granddad’s medical office building doesn’t cut it anymore,” said Don Orndoff, senior vice president, National Facilities Services.  “We’ve all now become accustomed to the Amazon and Uber experience and that’s our new expectation.”

The medical office of the future at Kaiser Permanente means harnessing design, technology and workflow to create an intuitive and convenient experience for members and care teams. It also means developing a much more agile and flexible environment that meets the evolving technology and service needs of those increasingly tech-savvy members and care teams.

Convenience and care under one roof

Signal Hill opened to Kaiser Permanente members on June 29, 2016, and its sleek architectural design doesn’t disappoint. But it’s the convenient technology features and efficient spaces inside that really impress. When you walk inside the building, you enter into the “public square.”

Since members have the option of checking in and handling their copayments at home, a quick visit to the kiosk allows them to take advantage of a number of options available to them in the public square. They can engage with others at the community table or use computers at the docking station. Or, they can decompress in a quiet spot on the upstairs “porch.” In fact, members can use their time wherever they wish because once the provider is ready, the member will receive a text message.

At the pharmacy, there is also no need to wait around. You’ll receive a text when your medication is ready.

signalhill2The exam rooms don’t look traditional either. Instead of the long, awkward exam table and steel chairs, there’s a comfortable reclining chair and a couch for family seating. The care team also uses hand-held tablets, which is not only easier for them, but avoids having the member stare at the back of a big computer monitor. On the wall, there’s a large monitor for virtual visits or patient education programs.

Read more of this story here. 

New resource to help identify and address social and non-medical needs

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Today marks the launch of the Social Interventions Research & Evaluation Network (SIREN) website, a new resource for health services researchers, clinicians, health system leaders, and others looking for evidence on what works to identify and address patients’ social and economic needs as a part of high quality health care.

Use the SIREN website to:

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On the site you’ll also see they are accepting applications for SIREN’s Innovation Grants. The Robert Wood Johnson Foundation and Kaiser Permanente have teamed up with SIREN to support a small number of research projects to advance our understanding of the health care costs and utilization impacts of addressing patients’ social determinants of health. Grants will provide up to $150,000 total funding over two years.

Letters of Intent are due May 15, 2017 and full applications are due June 15, 2017.

SIREN’s mission is to catalyze and disseminate high quality research that advances efforts to address patients’ social and economic needs in health care settings. Learn more here.

 

When Conventional Wisdom Becomes Outdated: How new perioperative guidelines can save time, pain, and cost

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Maurice Cates, MD, is an Orthopedic Surgeon at Kaiser Permanente’s Fredrick Medical Center. He is the chief of orthopedic surgery for the District of Columbia and Suburban Maryland as well as the regional medical director for musculoskeletal service.

Surgery has been around for thousands of years. The advances in technique, pain management, and outcomes have been remarkable. Since the advent of modern anesthesia, one thing has stayed pretty consistent; those dreaded pre-operative instructions not eat or drink anything after midnight the day of your surgery. Here is to hoping you’re scheduled in the morning, right?

qem2The thing about those instructions is that they may not be helping – especially in several types of cases, one of which is total joint replacement. While improvements in minimally invasive techniques have helped reduce length of stay for something like a knee replacement from well over a week to about 3.4 days in the past couple of decades, our work at the Mid-Atlantic Permanente Medical Group (MAPMG) is validating that it could be as short as 1-2 days in most cases. Several cases are achieving “same day discharge” and we have even completed a total knee replacement in our free standing ambulatory surgery center where the patient had no need to be admitted to a hospital at all.

One in 25 adults over 50 in America lives with a knee replacement. With that kind of volume, cutting length of stay by some 2 days per case, and potentially moving cases from hospitals to ambulatory surgery centers, could deliver a tremendous cost savings for American health care with no detriment to quality. To get there, more physician practices and hospitals need to embrace the mantra of evidence-based medicine and examine how to safely apply ERAS®, as MAPMG does, to its joint cases.

ERAS stands for Enhanced Recovery After Surgery. It represents a shift in care involving all aspects of the patient’s journey through the surgical process, from preoperative care through recovery. The whole idea is to reduce surgical stress and disruption to a patient’s baseline physiology. ERAS protocols, in brief, focus on: (1) allowing the patient to have liquids prior to surgery, (2) narcotic pain medicines are minimized (we use intravenous acetaminophen instead), and (3) eating and walking/ambulation as soon as possible after surgery. Implementation requires thoughtful development of end-to-end care pathways, decision trees, and detailed post-operative outcome measurements. Doctors, support staff, and administrators must be invested in patient-centric care, and having a cadre of talented surgeons helps too – just the ingredients we have at Kaiser Permanente.

Medical evidence in the modern world of health care is an ever-growing body of knowledge. The more organizations continuously look to new studies and those producing the best outcomes (even if it comes from outside the United States, as ERAS initially did), the more people can receive the best care possible. After all, who wants to lie in a hospital bed for 3-plus days when there is the possibility of going home the same or next day? Our patient satisfaction data bump for those having surgery with ERAS and getting early discharge versus the traditional approach suggests the answer is nearly no one.

Defining Success In Resolving Health-Related Social Needs

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A recent Health Affairs blog offers a perspective on the challenges of addressing the social needs of patients – particularly when the health care system at large doesn’t have common language to describe what a successful intervention might look like. Programs such as Kaiser Permanente’s Total Health initiative and CMS’ Accountable Health Community model screen participants for unmet social needs, yet there is lack of clear definition as to how the community – or delivery system – should be accountable for resolving these needs. This will continue to be a complex area for exploration as health care increasingly moves outside of the exam room into the community, and as we continue to look at how factors such as where our patients live, work, play and pray impact their overall health.

Read the blog here

Physician Leadership in the Movement Toward Accountable Care

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Blog by Elizabeth Keating
Senior Project Manager, Council of Accountable Physician Practices

“It will not be possible to move the country toward accountable, value-based care without strong physician leadership at all levels of the organization.”

This statement was made by Robert Pearl, M.D., CEO of the Permanente Medical Group and the Mid-Atlantic Permanente Medical Group. Dr. Pearl recently moderated a panel at the CAPG Colloquium held in Washington, DC, on September 29, 2016.

The panel, “Physician Leadership in the Movement Toward Accountable Care,” was hosted by the Council of Accountable Physician Practices (CAPP) and featured CAPP leaders discussing best practices in recruiting, training and developing physician leaders.

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“Healthcare systems should view physician leadership as a capital investment for the future with huge ROI,” said Dr. Pearl, who also serves as the chairman of the board of CAPP. “The CAPP medical groups are committed to sharing their considerable experience to help all provider organizations face the challenges ahead.”

Over the course of the discussion, the panel touched on key aspects of their physician leadership development approaches. All agreed that leadership development starts at the moment of recruitment into the organization.

“Every physician is a leader. We start with that assumption,” said Marc Klau, MD, Assistant Medical Director of SCPMG. “Take every physician on as a leader and then expand their capability, because you never know when you will need them.

Dr. Klau described how SCPMG’s expansive geography allows for unique leadership development opportunities because programs begin at the medical center level. He explained that each medical center allows emerging physician leaders to build programs that work toward the Triple Aim goal. He stressed that this display of clinical excellence is critical to growing as a physician leader, because it builds trust among peers.
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Dr. Klau also discussed how SCPMG’s leadership programs are geared toward training leaders in Permanente culture, not just administrative practices.

“It’s not about learning to log in to our electronic health record,” he said. “It’s about anchoring people in our history, quality expectations and developing communication skills.”

The panelists overwhelmingly agreed that physician leaders must possess emotional intelligence to be effective.

“The best leaders are going to be visionary but anchored in reality,” said Dr. Klau. “People who have a passion for doing something are the people who will move and change the world.”

The panelists agreed that physicians who are aspiring to lead their health systems or who think they might want to take on a more comprehensive role should start small. Emerging physician leaders could join clinical improvement committees or the first stage of a leadership program to determine if the track is right for them.

Can you see me now? Video Visits at Kaiser Permanente

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Dennis Truong, MD, is an emergency medicine specialist and the telemedicine director for the Mid-Atlantic Permanente Medical Group.

Smart phones and tablets are everywhere. Adoption of these devices now largely spans age, income, race and ethnicity. Americans, of all stripes, are emailing, tweeting, posting, banking, gaming, navigating, checking weather and so much more almost nonstop. Yet when it comes to using those nearly ubiquitous devices, only 2 percent report having access to video visits with their doctor.

In stark contrast, almost 9 in 10 family physicians believe telehealth – the suite of technologies and tactics to deliver virtual medical, health, and education services – is a way to increase access to care. Putting two and two together, that means far more than 2 percent of people should have access to video visits – a core component of telehealth.

Dr. Truong conducts a simulated video visit with a member.

Dr. Truong conducts a simulated video visit.

Why this disconnect? Telehealth regulatory policy for one. From the patchwork of state by state rules to privacy protections to reimbursement rules. Doctors (and some patients) also worry that telehealth has limited diagnostic and treatment value relative to face-to-face care and will adversely impact the day-to-day practice of an office. Not only does it interfere with the routine of quickly moving from one prepped patient to the next, it changes how you chart, plan for space in your office, bill and collect, and so much more.

The regulatory and payment framework must evolve, and technological advances in remote capabilities can help validate telehealth as a reliable solution. But it is easy to overlook the fact that none of it matters if doctors don’t want to change their norms. And, that adoption will fail if the consumer satisfaction barometer is not met as a result of a fragmented experience. At the Mid-Atlantic Permanente Medical Group (MAPMG), and all the Permanente groups of Kaiser Permanente, video visits have become a key part of our clinical offering. Making it work has been a case study in careful planning rather than chasing a “sexy” concept without judiciously working out all the details.

Since launching video visits three years ago, we carefully worked through the legal and regulatory steps. We put in the necessary equipment, trained every provider, collaboratively chose the specified set of clinical chief complaints that should be eligible for video, and slowly built video visit appointments into the schedule that gave physicians dedicated time for the care. The “competition” isn’t other providers. It is the doctor’s frame of reference. Is this as easy as when the patient is sitting in the exam room ready and waiting with forms completed, vitals collected, and nursing tasks done?

As the industry saw more platforms and pure-play video offerings emerge, we worked to stay true to a principle that says video care shouldn’t be fragmented from the normal care patients receive. Patients do not want to repeat themselves, pay for redundant tests, or fail to get a diagnosis because the doctor doesn’t have enough information to definitively make one. Nor do they want to have their “regular” doctor fail to provide care in consideration of what is known from any previous video encounters.

We purposefully integrated our solution into the same integrated electronic medical record we use for every face-to-face visit, telephone, or email visit. All the information is there to make the right clinical call. The ordering and referring process is identical (and can be done for the patient by the provider). The activity is visible to the patient’s regular provider(s).

When practiced right, it becomes as clear as the face on that smart phone screen that video visits are a powerful tool to improve access and patient satisfaction. The medical community needs to invest in making it not simply available to more patients, but making it available in a way that allows them to integrate that care with their overall primary and specialty care.

Transgender Health Meet and Greet

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In 2013, we hosted a first conversation, the Transgender Health Care Dialogue. In 2016, we hosted our next, Transgender Health Meet and Greet.

A lot has happened in three years, in our society, in the medical profession, and at Kaiser Permanente. The 2016 event included physicians, nurses, and health leaders from Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Medical Group, and The Southeast Permanente Medical Group.

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They joined with the Washington, DC, Maryland, and Virginia LGBTQ community to meet Drs. Kathy Rumer and Rachel Bluebond-Langner to learn about surgical care for people who are transgender or gender non-conforming – hence “Transgender Health Meet and Greet.”

It’s an honor to participate in the future of care delivery at Kaiser Permanente, an organization that values the diversity and inclusion of our lesbian, gay, bisexual, and transgender members (and staff).

Total Health definitely includes the doctors, nurses, and health care system that enable people to live as their authentic selves, as members, as caregivers, as leaders in their communities. I can’t wait to see what happens next.

National HIV Testing Day

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For National HIV Testing Day, 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. 

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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.”

Authors:

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

Don’t Let a Failing Heart Relegate You to Endless Doctor and Hospital Visits

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Dr. Ameya Kulkarni is an interventional cardiologist with the Mid-Atlantic Permanente Medical Group.

No one wants to spend their days in a hospital room. For the more than 5 million people in America who live with heart failure, a hospital stay is an unfortunate fact of life. In fact, it is estimated that there are over 1 million hospitalizations for people with this condition every year. The burden on patients, their families and their communities is immense. And the cost of this care is so high that there is a currently a national focus on trying to drive down admissions to the hospital for heart failure.

The Kaiser Permanente Center for Total Health regularly updates the information in our displays in collaboration with our health systems partners in Kaiser Foundation Health Plan and the Permanente Medical Groups. The Q1 2016 update focuses on Quality & Expert medicine, as led and delivered by the Mid-Atlantic Permanente Medical Group.

The Kaiser Permanente Center for Total Health regularly updates the information in our displays in collaboration with our health systems partners in Kaiser Foundation Health Plan and the Permanente Medical Groups. The Q1 2016 update focuses on Quality & Expert medicine, as led and delivered by the Mid-Atlantic Permanente Medical Group.

So far, the ideas on how to solve this problem mostly treaded old paths – exchanging hospitalizations for more doctor office visits. We know that patients end up in the hospital when they fill with fluid. Signs of this fluid buildup (increased weight, decreased activity) usually show up well before the need for a hospitalization. Our solution so far has been to have patients come to the doctor’s office more frequently for weight and activity checks. Although cumbersome for both the patient and the clinical care team, at least coming to the doctor every week keeps these patients out of the hospital.

It does not, however, make patients happier. Although no one wants to be in a hospital, few long for frequent battles with traffic only to pay a copay and wait for a doctor to review their weight and activity and make a small medication adjustment.

The innovation team at the Mid-Atlantic Permanente Medical Group – the independent medical group that exclusively serves Kaiser Permanente members in Washington, D.C., Maryland, and Virginia – has a vision of using 21st century technology to keep a close watch on our patients without the burdens of the traditional face-to-face visit.

We know that an early signal that a patient with congestive heart failure (CHF) will land in a hospital is a decrease in activity or an increase in weight. So we are giving our patients connected monitors that measure these parameters and send them to the care team automatically. We do the rest. When patients are doing fine, we don’t bother them. But when we get a signal that things aren’t going so well, we can reach out to make an adjustment before the fluid retention gets out of hand.

Better Together Health, with Council of Accountable Physician Practices

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Innovations in chronic care were featured in the Council of Accountable Physician Practices (CAPP) event at the Center for Total Health on June 15.

Hosted by The Permanente Medical Group Executive Director and CEO Robert Pearl, MD, the event was keynoted by Senator Johnny Isakson (R-GA), co-chair of the Senate Finance Committee’s Chronic Care Working Group. A lively panel discussion moderated by Ceci Connolly, President and CEO of the Alliance of Community Health Plans (ACHP), included patient stories that highlight the importance of care coordination and patient engagement in managing chronic conditions. Kaiser Permanente Southern California’s “complete care” diabetes program was featured through a member video and a description from Dr. Marc Klau, SCPMG Assistant Regional Medical Director for Education, Learning and Leadership. Tim Gronninger of CMS also gave remarks and joined the panel for questions.

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The Council of Accountable Physician Practices also released its second annual poll of patients and physicians, which measures patient expectations, use of technology enabled care, and the pace of progress in bring “high tech, high touch” care to patients while making it easy for physicians and the care team to provide.