Perceptions and Experience of Patients, Staff, and Clinicians with Social Needs Assessment.

CONTEXT: Assessment of social needs is expanding at Kaiser Permanente (KP), but little is known about how members and clinicians experience the incorporation of social needs into health care. OBJECTIVE: To assess how KP members and clinicians experience social needs assessments incorporated into care. DESIGN: Qualitative and descriptive analysis of data from member and clinician focus groups, interviews, and surveys among 68 members and family caregivers who had participated in social needs assessment programs and 90 clinicians and staff in the KP Colorado, Georgia, Northern California, Northwest, and Southern California Regions. MAIN OUTCOME MEASURES: Members' and clinicians' perceptions and experiences of social needs assessment. RESULTS: Members and clinicians understood the impact of social needs on health and why a health care system representative would ask about food, housing, transportation, and other social needs. Members and clinicians supported social needs assessment at KP and agreed that KP should help address identified social needs. However, both groups emphasized the importance of assessments yielding actionable information. Members were also concerned about how the information would be used and by whom. CONCLUSION: Our findings support the continuing assessment of social needs at KP and identify issues that require attention as it expands. Assessment should not outpace organizational capacity to connect members with resources. Careful attention to communications is required because members may be uncertain or concerned about the purpose of the assessment and the dissemination of sensitive information. Messaging should assure members about data use and dissemination and what they can expect after screening.

Complete care at Kaiser Permanente: transforming chronic and preventive care.

BACKGROUND: In 2004 Kaiser Permanente Southern California (KPSC) recognized the potential to improve the quality of care. Healthcare Effectiveness Data and Information Set (HEDIS) performance was below what regional leadership aspired to achieve, exceeding the 90th national percentile on only 15 of 34 measures. Beginning in 2005 regional leadership identified several system opportunities to enhance evidence-based, person-focused care. DEVELOPMENT OF COMPLETE CARE: KPSC developed and implemented a comprehensive delivery system redesign and expanded and integrated existing clinical information systems, decision support, work flows, and self-management support-collectively referred to as Complete Care. The goal of Complete Care is to transform care for healthy members, those with chronic conditions, and those with multiple comorbidities. To date, KPSC has applied Complete Care to 26 chronic conditions and areas of preventive and wellness care. Implemented in all care settings and optimizing the roles of all health care team members to maximal scope of practice, Complete Care provides evidence-based, person-focused care addressing a large set of protocol-based health needs for every individual during every encounter within the health care system. RESULTS: On 51 HEDIS metrics, KPSC improvement using Complete Care averaged 13.0%, compared with 5.5% improvement in the national HEDIS 50th percentile. CONCLUSION: Implementation of Complete Care at KPSC was followed by six-year quality gains that outpaced changes in the HEDIS national percentiles for many measures. Additional care gaps have been included in proactive office encounter checklists; these relate to elder care, advance directives, posthospital care, immunizations, health maintenance, and pregnancy care.

How Kaiser Permanente uses video ethnography of patients for quality improvement, such as in shaping better care transitions.

Keeping patients and caregivers at the center of quality improvement is critical. Kaiser Permanente's Care Management Institute adapted video ethnography to achieve this aim, using video to capture interviews with-and observations of-patients and caregivers, identify patient-centered improvement opportunities, and communicate them effectively to clinical and administrative leaders and front-line staff. This method is particularly effective for helping understand the needs of frail elders, patients nearing the end of life, those with multiple chronic conditions, and other vulnerable people who are not well represented in focus groups and patient advisory councils. As part of an initiative to improve care transitions for elders with heart failure, video ethnography contributed to greatly reduced thirty-day hospital readmission rates, helping reduce readmissions at one medical center from 13.6 percent to 9 percent in six months. It also helped improve the reliability of the readmissions reduction program. When embedded within an established quality improvement framework, video ethnography can be an effective tool for innovating new solutions, improving existing processes, and spreading knowledge about how best to meet patient needs.

Self-management support to people with type 2 diabetes - a comparative study of Kaiser Permanente and the Danish Healthcare System.

BACKGROUND: Self-management support is considered to be an essential part of diabetes care. However, the implementation of self-management support within healthcare settings has appeared to be challenging and there is increased interest in "real world" best practice examples to guide policy efforts. In order to explore how different approaches to diabetes care and differences in management structure influence the provision of SMS we selected two healthcare systems that have shown to be comparable in terms of budget, benefits and entitlements. We compared the extent of SMS provided and the self-management behaviors of people living with diabetes in Kaiser Permanente (KP) and the Danish Healthcare System (DHS). METHODS: Self-administered questionnaires were used to collect data from a random sample of 2,536 individuals with DM from KP and the DHS in 2006-2007 to compare the level of SMS provided in the two systems and identify disparities associated with educational attainment. The response rates were 75 % in the DHS and 56 % in KP. After adjusting for gender, age, educational level, and HbA1c level, multiple linear regression analyses determined the level of SMS provided and identified disparities associated with educational attainment. RESULTS: Receipt of SMS varied substantially between the two systems. More people with diabetes in KP reported receiving all types of SMS and use of SMS tools compared to the DHS (p < .0001). Less than half of all respondents reported taking diabetes medication as prescribed and following national guidelines for exercise. CONCLUSIONS: Despite better SMS support in KP compared to the DHS, self-management remains an under-supported area of care for people receiving care for diabetes in the two health systems. Our study thereby suggests opportunity for improvements especially within the Danish healthcare system and systems adopting similar SMS support strategies.

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

OBJECTIVE: To understand factors leading to all-cause 30-day readmissions in a community hospital population. RESEARCH DESIGN: Structured case series of 537 readmissions using chart reviews, interviews with treating physicians, patients and family caregivers, and overall case assessment by a nurse-physician team. SETTING: Eighteen Kaiser Permanente Northern California hospitals. RESULTS: Forty-seven percent (250) of readmissions were assessed as potentially preventable; 11% (55) were assessed as very or completely preventable; and 36% (195) as slightly or moderately preventable. On average, 8.7 factors contributed to each potentially preventable readmission. Factors were related to care during the index stay (in 143 cases, 57% of potentially preventable readmissions), the discharge process (168, 67%), and follow-up care (197, 79%). Missed opportunities to prevent readmissions were also related to quality improvement focus areas: transitions care planning and care coordination, clinical care, logistics of follow-up care, advance care planning and end-of-life care, and medication management. CONCLUSIONS: Multiple factors contributed to potentially preventable readmissions in an integrated health care system with low baseline readmission rates. Reducing all-cause 30-day readmissions may require a comprehensive approach addressing these areas. Future quality improvement efforts and research should identify existing and new tactics that can best prevent readmissions by addressing missed opportunities we identified.

Effective population management practices in diabetes care - an observational study.

BACKGROUND: Ensuring that evidence based medicine reaches patients with diabetes in the US and internationally is challenging. The chronic care model includes evidence based management practices which support evidence based care. However, despite numerous studies, it is unclear which practices are most effective. Few studies assess the effect of simultaneous practices implemented to varying degrees. The present study evaluates the effect of fifteen practices applied concurrently and takes variation in implementation levels into account while assessing the impact of diabetes care management practices on glycemic and lipid monitoring. METHODS: Fifteen management practices were identified. Implementation levels of the practices in 41 medical centres caring for 553,556 adults with diabetes were assessed from structured interviews with key informants. Stepwise logistic regression models with management practices as explanatory variables and glycemic and lipid monitoring as outcome variables were used to identify the diabetes care practices most associated with high performance. RESULTS: Of the 15 practices studied, only provider alerts were significantly associated with higher glycemic and lipid monitoring rates. The odds ratio for glycemic monitoring was 4.07 (p < 0.00001); the odds ratio for lipid monitoring was 1.63 (p < 0.006). Weaker associations were found between action plans and glycemic monitoring (odds ratio = 1.44; p < 0.03) and between guideline distribution and training and lipid monitoring (odds ratio = 1.46; p < 0.03). The covariates of gender, age, cardiac disease and depression significantly affected monitoring rates. CONCLUSIONS: Of fifteen diabetes care management practices, our data indicate that high performance is most associated with provider alerts and more weakly associated with action plans and with guideline distribution and training. Lack of convergence in the literature on effective care management practices suggests that factors contributing to high performance may be highly context-dependent or that the factors involved may be too numerous or their implementation too nuanced to be reliably identified in observational studies.

Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system.

BACKGROUND: Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. METHODS: Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. RESULTS: More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. CONCLUSIONS: More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

Medication use, emergency hospital care utilization, and quality-of-life outcome disparities by race/ethnicity among adults with asthma.

OBJECTIVES: To examine the association of race/ethnicity with medication use, emergency hospital care (EHC) utilization, and quality-of-life outcomes in a population with persistent asthma and to determine if factors related to severity of illness, treatment characteristics, and demographic, socioeconomic, and smoking status explain differences in study outcomes. STUDY DESIGN: Retrospective analysis. METHODS: We examined survey and administrative data for 974 adults with persistent asthma enrolled in a group-model health maintenance organization. Patients with persistent asthma were identified in 1999 using Healthcare Effectiveness Data and Information Set inclusion criteria. In 2000, the same patients were surveyed regarding quality of life using the Mini Asthma Quality of Life Questionnaire. In 2001, the use of controller medications, the ratio of controller medications to rescue medications, and EHC utilization were identified by electronic medical record. Multiple logistic regression and linear regression analyses were used to evaluate the independent association of race/ethnicity with study outcomes after adjusting for severity of illness, treatment characteristics, and demographic, socioeconomic, and smoking status. RESULTS: Compared with whites, African Americans (standardized ß coefficient, -0.12) and Native Americans/Aleutians/Eskimos (standardized ß coefficient, -0.14) had lower Mini Asthma Quality of Life Questionnaire scores (P <.05 for both). African Americans were significantly (P <.05) more likely to report EHC utilization (odds ratio, 5.2; 95% confidence interval, 2.6-10.3). CONCLUSIONS: Disparities existed in 2 outcome measures, Mini Asthma Quality of Life Questionnaire scores and EHC utilization. A concerning finding is that African Americans were at least 5 times more likely to report higher EHC utilization, even after adjusting for factors such as income and education.

Rapid spread of complex change: a case study in inpatient palliative care.

BACKGROUND: Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. METHODS: Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. RESULTS: Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. CONCLUSIONS: A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.

Coordination of diabetes care in four delivery models using an electronic health record.

BACKGROUND: Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is not well understood. OBJECTIVES: To identify processes by which providers worked together to provide care using an EHR and to examine factors supporting coordination of care. DESIGN: Qualitative multiple case study in 4 sites with diverse care delivery models, using semi-structured in-person interviews with 46 physicians and staff and telephone interviews with 65 adult patients with diabetes. SETTING: Four Kaiser Permanente medical centers. RESULTS: Across all care models, physicians and staff acted sequentially as loosely coupled links in a chain, relying on EHR-enabled informational continuity to coordinate care. Of providers, 94% were highly satisfied with the availability of patient information, and 89% of patients were satisfied or very satisfied with the coordination of their care. However, 6 of 65 patients described experiences of uncoordinated care, and 5 of 12 primary care providers identified coordination issues. These pertained to unreconciled differences of opinion, conflicting role expectations, and discipline-specific views of patient needs. CONCLUSIONS: Diabetes care can be coordinated across providers, but some coordination issues persist despite the informational continuity provided by an EHR. Multidisciplinary care teams should be alert to potential coordination challenges, and possible solutions should be explored, including longitudinal care planning with structured communications at key points in care.

Care coordination and electronic health records: connecting clinicians.

OBJECTIVE: To examine the association between use of electronic health records (EHR) and care coordination. STUDY DESIGN: Two surveys, in 2005 and again in 2006, of primary care clinicians working in a prepaid integrated delivery system during the staggered implementation of an EHR system. Using multivariate logistic regression to adjust for clinician characteristics, we examined the association between EHR use and clinicians' perceptions of three dimensions of care coordination: timely access to complete information; treatment goal agreement; and role/responsibility agreement. RESULTS: Compared to clinicians without EHR, clinicians with 6+ months of EHR use more frequently reported timely access to complete information, and being in agreement on treatment goals with other involved clinicians. There was no significant association between EHR use and being in agreement on roles and responsibilities with other clinicians. CONCLUSIONS: EHR use is associated with aspects of care coordination involving information transfer and communication of treatment goals.

A retrospective analysis of health systems in Denmark and Kaiser Permanente.

BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy. METHODS: Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability. RESULTS: A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with 134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS). CONCLUSION: Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.

Patient Assessment of Chronic Illness Care (PACIC) and improved patient-centered outcomes for chronic conditions.

BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral and quality measures for patients with chronic conditions. OBJECTIVE: To examine the relationship between PACIC scores and self-management behaviors, patient rating of their health care, and self-reported quality of life. DESIGN: Cross-sectional survey with a 61% response rate. PARTICIPANTS: Included in the survey were 4,108 adults with diabetes, chronic pain, heart failure, asthma, or coronary artery disease in the Kaiser Permanente Medical Care program across 7 regions nationally. MEASUREMENTS: The PACIC was the main independent variable. Dependent variables included use of self-management resources, self-management behaviors such as regular exercise, self-reported adherence to medications, patient rating of their health care, and quality of life. RESULTS: PACIC scores were significantly, positively associated with all measures (odds ratio [ORs] ranging from 1.20 to 2.36) with the exception of self-reported medication adherence. CONCLUSIONS: Use of the PACIC, a practical, patient-level assessment of CCM implementation, could be an important tool for health systems and other stakeholders looking to improve the quality of chronic disease care.

How well do the HEDIS asthma inclusion criteria identify persistent asthma?

OBJECTIVES: (1) To determine if the Health Plan Employer Data and Information Set (HEDIS) asthma inclusion criteria consistently identify persistent asthma on a year-to-year basis and (2) to explore whether variation in the number of years of qualification is associated with medication and resource utilization outcomes. STUDY DESIGN: Retrospective observational study. METHODS: We identified 132 414 patients in a large healthcare program who were included in 1 or more HEDIS persistent asthma cohorts between 1999 and 2002 and who had continuous insurance and pharmacy benefit coverage for the entire 4-year observation period. Medication, emergency department, and hospital use in 2002 was identified using electronic claims and pharmacy information. RESULTS: Overall, 47.9% of the patients were identified as having persistent asthma in only 1 of 4 years, 40.8% had at least 2 consecutive years, and 28.2% had at least 3 consecutive years. In bivariate and multivariate analyses, more consecutive years of HEDIS persistent asthma qualification significantly increased the likelihood of frequent short-acting b-agonist use, inhaled antiinflammatory corticosteroid use, at least 1 emergency department visit, and at least 1 hospitalization. The strongest relationship was for 3 or more consecutive years of HEDIS qualification. CONCLUSIONS: A significant portion of the HEDIS persistent asthma cohort does not qualify on a year-to-year basis, suggesting that the current 1-year qualification period or the underlying administrative case definition for persistent asthma may be suboptimal. Further clinical validation studies are needed to determine the optimal criteria for a more useful HEDIS persistent asthma case definition.