Dementia Ideal Care: Ecosystem Map of Best Practices and Care Pathways Enhanced by Technology and Community.

Background: Globally, much work has been done by nonprofit, private, and academic groups to develop best practices for the care of people living with dementia (PLWD), including Alzheimer's disease. However, these best practices reside in disparate repositories and tend to focus on one phase of the patient journey or one relevant group. Objective: To fill this gap, we developed a Dementia Ideal Care Map that everyone in the dementia ecosystem can use as an actionable tool for awareness, policy development, funding, research, training, service delivery, and technology design. The intended audience includes (and not limited to) policymakers, academia, industry, technology developers, health system leaders, clinicians, social service providers, patient advocates, PLWD, their families, and communities at large. Methods: A search was conducted for published dementia care best practices and quality measures, which were then summarized in a visual diagram. The draft diagram was analyzed to identify barriers to ideal care. Then, additional processes, services, technologies, and quality measures to overcome those challenges were brainstormed. Feedback was then obtained from experts. Results: The Dementia Ideal Care Map summarizes the ecosystem of over 200 best practices, nearly 100 technology enablers, other infrastructure, and enhanced care pathways in one comprehensive diagram. It includes psychosocial interventions, care partner support, community-based organizations; awareness, risk reduction; initial detection, diagnosis, ongoing medical care; governments, payers, health systems, businesses, data, research, and training. Conclusions: Dementia Ideal Care Map is a practical tool for planning and coordinating dementia care. This visualized ecosystem approach can be applied to other conditions.

Increasing pneumococcal vaccination in managed care through telephone outreach.

OBJECTIVES: To determine the effectiveness of a telephone reminder to increase pneumococcal vaccination in a population that had received mailed reminders and to evaluate whether the intervention effect is similar for clinics serving primarily non-Hispanic black or non-Hispanic white patient populations. STUDY DESIGN: Randomized trial within a managed care network. METHODS: All unvaccinated patients 18 years and older with chronic medical conditions and 65 years and older without chronic medical conditions (N = 6106) were randomized to receive telephone intervention or standard care and followed up for 6-month vaccination status. The intervention was a telephone call initiated by a nurse to inform patients that pneumococcal vaccination was recommended and was a covered benefit of their insurance. RESULTS: Intervention patients were 2.3 times as likely to be vaccinated during the study period than control patients (P < .001). The success of telephone intervention versus control was similar across clinics (P = .16) and across the chronic disease and elderly groups (P = .14). In subanalyses of individuals reached by telephone intervention, unvaccinated black subjects were less likely to be vaccinated during the study than unvaccinated white subjects (34% vs 25%, P = .03). Nurse staff time for telephone intervention cost $147.35 per additional patient vaccinated. CONCLUSIONS: Telephone intervention was successful at increasing vaccination rates in a diverse managed care population that had already received mailed reminders. Tailored messaging for pneumococcal vaccination through telephone reminders increases patient demand for vaccination and should be implemented by managed care organizations seeking to increase their vaccination rates.

Web-based weight management programs in an integrated health care setting: a randomized, controlled trial.

OBJECTIVE: To assess the efficacy of a Web-based tailored behavioral weight management program compared with Web-based information-only weight management materials. RESEARCH METHODS AND PROCEDURES: Participants, 2862 eligible overweight and obese (BMI = 27 to 40 kg/m2) members from four regions of Kaiser Permanente's integrated health care delivery system, were randomized to receive either a tailored expert system or information-only Web-based weight management materials. Weight change and program satisfaction were assessed by self-report through an Internet-based survey at 3- and 6-month follow-up periods. RESULTS: Significantly greater weight loss at follow-up was found among participants assigned to the tailored expert system than among those assigned to the information-only condition. Subjects in the tailored expert system lost a mean of 3 +/- 0.3% of their baseline weight, whereas subjects in the information-only condition lost a mean of 1.2 +/- 0.4% (p < 0.0004). Participants were also more likely to report that the tailored expert system was personally relevant, helpful, and easy to understand. Notably, 36% of enrollees were African-American, with enrollment rates higher than the general proportion of African Americans in any of the study regions. DISCUSSION: The results of this large, randomized control trial show the potential benefit of the Web-based tailored expert system for weight management compared with a Web-based information-only weight management program.

Kaiser Permanente Georgia's Experience with Operation Zero: A Group Medical Appointment to Address Pediatric Overweight.

CONTEXT: The rate of overweight (OW) in children in the United States has more than tripled since 1980. The health consequences of pediatric OW include type 2 diabetes and significant illness later in life. Treating pediatric OW is a necessity; however, health care clinicians have minimal access to successful and comprehensive treatment modalities for addressing it. OBJECTIVE: Kaiser Permanente of Georgia (KPGA) offers a group medical appointment clinic, Operation Zero (O.Z.), as a referral program for preadolescent and adolescent patients who are in the 85th or higher percentile for body mass index (BMI) for their age. The eight-session clinic uses a family-oriented approach and provides a supportive group environment with interactive learning, games, physical activity, and creative problem solving. The goal of the program is to improve lifestyle behaviors for nutrition and physical activity. Clinically, meeting these goals can manifest as reductions in body fat (BF), waist size, and BMI-for-age percentile. Two implementation models help improve dissemination of the program within KPGA. DESIGN: Baseline and eight-week postclinical outcomes for O.Z. participants were analyzed to determine program effectiveness. A retrospective analysis with a control group looked at long-term clinical outcomes to determine weight maintenance. Main outcome measures were weight, BMI-for-age percentile, waist size, and percentage of body fat (%BF). RESULTS: At eight weeks after program completion compared with baseline, there were significant reductions in %BF and waist size for the total sample and specifically for adolescents, preteens, and participants who attended six or more sessions. Among O.Z. participants, there were insignificant increases in weight at six months after program participation and BMI-for-age percentile at one year after participation. At six months, the mean change in weight and BMI in the O.Z. group was statistically less than the mean change in the control group. CONCLUSIONS: A structured, family-oriented weight management program is effective in changing measures consistent with improved weight management.

Mammography screening: addressing myths and other reasons for noncompliance.

In the Kaiser Permanente (KP) Georgia Region, a program of extensive mailings, call center contacts, and other avenues of patient education has been designed to increase the number of women having mammograms and to decrease the mortality rate from breast cancer. Citing statistics from various studies nationwide and in the Atlanta area, the authors outline some reasons for patient resistance to mammography and describe the resulting development of a "patient fact sheet" and other interventions intended to increase the rate of screening mammograms conducted in our target population of KP members.

Factors Associated with Smoking Cessation Among Quit Smart(™) Participants.

OBJECTIVES: To evaluate social and program factors associated with the one-year smoking cessation rate among participants of a smoking cessation program at a managed care organization (MCO). METHODS: As implemented at this MCO, the Quit Smart(™) program incorporated group sessions taught by health educators, discount vouchers for nicotine replacement patches, self-help manuals, and a relaxation audiotape. A survey of 97 patients who participated in the program during 1999 or 2000 or both was administered one year after these participants completed the program. RESULTS: Of the 97 participants, 58 responded to the survey. Nineteen (33%) reported not smoking at one year after completing the program; and 11 (19%) reported that they were smoking-abstinent for 12 months after completing the program. Compared with patients who did not use the nicotine patch, respondents who used the nicotine patch were significantly more likely (OR = 4.42 [1.12, 17.35]) to report not smoking at 12 months after completing the program and to be smoking-abstinent for 12 months after completing the program (OR = 8.31 [1.15-60.22]). Respondents who were exposed to smoking in two or three settings (ie, at home, with friends, at work) were significantly less likely to report smoking cessation at 12 months (OR = 0.12 [0.02, 0.70]) and to have abstained from smoking for 12 months (OR = 0.04 [0.01, 0.42]) than were respondents who were not exposed to smoking in these settings. CONCLUSIONS: The Quit Smart(™) program achieved 12-month smoking cessation and abstinence rates comparable with those achieved by other multifactorial programs to promote smoking cessation. Subsidized therapy using the nicotine patch was effective for promoting smoking cessation. However, program success was inhibited by exposure to smoking in domestic and social situations.

The search for value in health care: a review of the National Committee for Quality Assurance efforts.

Large employers formed the National Committee for Quality Assurance (NCQA) to ensure value to healthcare purchasers. Value in healthcare is a function of quality divided by costs. Through NCQA's role as an accrediting agency for healthcare organizations and the development of performance measures, Health Plan Employer Data and Information Set (HEDIS), gains toward defining the value of health services have materialized. An analysis of the impact of HEDIS data collection on physician practices and the influence of HEDIS data on employer, employee, and governmental health plan selections is examined. This study consisted of a general review, from 1993 to 2001, of HealthStar databases, PubMed databases, and the NCQA website. NCQA accreditation is accepted as an important industry milestone for health plans, credentials verification organizations, and physician organizations. The data for HEDIS is collected from health plan administrative data repositories, whereas health plan members' clinical data may be collected by chart abstraction in physician offices. Data collection in physician offices consumes administrative resources from physician practices and health plans. As commercial and governmental insurers move toward greater adoption of HEDIS measures, complex implications are created for physician practices and vulnerable populations. There are lingering questions regarding the improvements in quality of care for medically underserved populations and physician practice costs attributable to HEDIS.