Kaiser Permanente Patient Centered Medical Homes Lessons Learned

Kaiser Permanente Patient Centered Medical Homes: Lessons Learned in Two Residencies and Applicable Elsewhere Timothy A. Munzing M. D. Walt Mills, M. D. May 2008

New Medical Home l Objectives: 1. 2. 3. Describe how Kaiser Permanente is redesigning for Pt. Centered Medical Homes Describe how 2 KP residencies are teaching this to faculty and residents Explore how curricular areas may be used – EHR, Chronic Dz Mgmt, Secure Messaging, Advanced Access, Group Visits, etc.

ACGME Competencies 1. 2. 3. 4. 5. 6. Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice

Kaiser Permanente Orange County l l l l Founded 1994 18 Residents – 6/6/6 100% Managed Care – 385, 000 patients 2 medical centers Suburban Southern California FMC – 50% Latino population Family Physician faculty – 9 Admin & 25 Total (department of 140 FP’s)

Family Medicine is new to NC Residency Programs

Santa Rosa Family Medicine Residency Consortium established 2007 l l l General Practice Internship Founded 1938 One of first Family Medicine Residencies 1968 36 Residents (12 -12 -12) 9 Core Faculty; 211 Consortium Faculty; one FPC; 3 hospitals New Fellowship in Integrative Medicine 2008 Transitioning from Sutter (Community) Hospital to Consortium – Kaiser Institutional GME Sponsor l l l Kaiser pays salary, wages, benefits for 36 Residents; Faculty Development, Consortium Administration Sutter Foundation employs most Core Faculty still Federally Qualified Health Clinic runs Family Medicine Center Memorial Hospital other major Hospital Campus UCSF Affiliate Consortium Board: Kaiser, Sutter, Memorial, Southwest Community Health Centers, UCSF, County Health, Residency

Patient Center Medical Home Attributes l l l l Patient-centered care Whole-person orientation Care provided within a community context Team approach Elimination to barriers of access Advanced information systems Emphasis on quality and safety Enhanced practice finance Commitment to provide basket of services ww. annfammed. org/cgi/content/full/2/suppl_1/s 3/T 4 l

Basket of Services - New Model l l l Health care provided to children and adults Integration: coordinate and facilitate care Disease prevention and health promotion Patient education and support for self-care Diagnosis and management of acute injuries and illnesses Diagnosis and management of chronic diseases Supportive care, including end-of-life care Maternity care; hospital care Primary mental health care Consultation and referral services as necessary Advocacy for the patient within the health care system Quality improvement and practice-based research http: //www. annfammed. org/cgi/content/full/2/suppl_1/s 3/T 5

Teaching New Model of Family Medicine 2008 SR Family Medicine Residency Self Assessment GPA=2. 0 (C) l l l Open access scheduling (D) Online appointments (F) Electronic health record (D) Group visits (B) E-visits (F) Chronic disease management (C) l l l Web-based information (B) Team approach (B+) Guideline software (B) Outcomes analysis (D) Alternative payment models (C)

FPC Current Paper Charts l l 2008 e. Clinical Works EMR Model Office Re-design

New Building = New Model 2010

P 4 Project-Santa Rosa Program l l 2006 Santa Rosa FMR was in final 40 applications for P 4 P (Preparing Physicians to Practice Primary Care in the 21 st Century) 2007 Established a P 4 Program Development Plan – – – Faculty Development 2007 -2012 Program (Kaiser Grant) Curriculum Development “Bridges to Excellence” 2008 -2010 Model Office Planning 2007 -2010 l l New Building 2010 Electronic Health Record FPC – e. Clinical Works 2008

“Bridges to Excellence” Project: Kaiser Family Medicine Department Offsite Asked the question “What is KP stellar at? What does it want to be known for within Residency Education? How Kaiser contribute to training the next generation of Family Physicians? l l l l Service and Access Quality Population Based Medicine Chronic Disease Management Preventive Medicine Evidence Based Medicine Information Technology Group Visits Health Education and Promotion Integrated Model of Care System Based Care Professionalism-communication (Four Habits Model) Team Based Care Culturally Sensitive Care (establishing Latino Clinic Module) Community Based Medicine

Bridges to Excellence Program Development l l Background: Transfor. MED, an AAFP practice redesign initiative, six-year project, is asking that Residency’s develop curriculum “Preparing the Personal Physician for Practice”, or P to the fourth power, P 4. The Workgroup proposes FMS develop a P 4 P curriculum General Principles: Will be integrated into Kaiser FMS Department with Key Faculty during R 2 and/or R 3 years Resident seeing pts in our department Curriculum designed to maximize Residents acquisition of tools to practice medicine in 21 st Century New Model for care – Theory and applications of Pop Mgmt, Adv Access, E-Med, Panel Mgmt, Chronic Disease Mgmt, Service Excellence, QI

Consortium Faculty Development Program 2007 -2012 l l l Q 6 months Workshops focused on New Model Teaching New FPC Ambulatory Care Curriculum; Evaluations emphasizing the Six Competencies applied to New Model New Preceptor Training (with EMR, New Innovations, and Audiovisual Precepting) Effective Faculty Evaluations and Professional Development (KP $125, 000 Grant) New Model Family Medicine Fellowships – l First is Integrative Medicine Fellow emphasizing “Relationship Centered Medicine” Residency Solutions Program Consultation and Five Year Consortium Business Plan promoting “Residency Excellence”

Improved Quality Outcomes 2004 2005 2006 2007 DM LDL < 100 42. 8 51. 9 53. 7 55. 7 CAD LDL < 100 50. 4 65. 7 71. 1 83. 4 HTN Control 62. 2 72. 8 82. 2 84. 7 Breast CA Screen 83. 4 80. 7 85. 8 87. 8 Cervical CA Screen 81. 2 83. 2 84. 3 86. 4 Colon CA Screen 40. 1 60. 9 67

Embed the “Right Thing to Do” into Every Point of Care Primary Care • Reminder/Prompts • Diabetes Lab Panel • Access to Registry Call Center/ Advice Nurse • Scripts • Protocols Hospital • Reminders/Prompts • Treatment Protocols • Standing Orders • Blood Sugar Testing as Vital Sign Emergency Room Specialty Care • Reminder/Prompts • Diabetes Lab Panel • Access to Registry Member Centered Care Management Rehabilitation Facility • Reminder/Prompts • Standing Orders • Protocols Urgent Care • Reminders/Prompts Care/Case Management • Protocols Skilled Nursing Facility Pharmacy Home Adapted from: Hyatt JD, Benton RP, Derose SF, JCOM, April 2002 • Outreach Letters • Telephone Outreach • Flu Shot Reminders • Healthphone • Healthwise Handbook • Member Web site • Remote Monitoring Laboratory • Automated Standing Orders • Protocols • Alerts • Counseling Health Education

Patient Satisfaction l l ASQ MPS Meteor Individual Physician Satisfaction Scores (Average 9. 35 out of 10)

Access Measures l l l Panel Management Bonding Rates (% of time PCP’s patients saw the PC) Patient’s perception of access - survey

Chronic Disease Management l l l Major emphasis of the ambulatory curriculum Intervention both prospective and retrospective In reach and outreach

Metrics Tracked l l l l l Breast Ca Screening l Cervical Ca Screening Colon Ca Screening HTN in control Osteoporosis Screening Peds Immunization l Adult Immunization l Asthma – IAI / BAG use Smoking advice Diabetes – – – Hgb. A 1 c < 7. 0 LDL < 100 Retinal Screening Foot Exam ACE-I use CAD – LDL <100 Chlamydia Screening

Quality Improvement l Ambulatory Based Quality Metrics – – – Medication Usage Evaluation l Non-formulary medication use l Antibiotic utilization Patient Satisfaction Scores by individual physician Performance Improvement l Clinical Strategic Goals l Chronic Disease Management l Family Medicine Quality Newsletter l Appropriate use of ambulance services

Chronic Disease Management (Transitioning to Patient Centered Approach) February May August November HTN CAD LDL testing CAD LDL>100 DM LDL >100 March June September December DMA 1 c >7 DM A 1 c testing DM foot exam DM retinal photos Colon CA screening January April July October Smoking Cessation Pneumovax and other immunizations Pap Mammography Asthma

Chronic Disease Management Can drill to individual physician and patient

Quality Improvement - Hospital l Hospital-Based Quality Metrics – – – – Transfused to Cross-matched Ratio Hospital Deaths Hospital Readmissions within 48 hours Medical Records (dictations and pharmacy orders) Hospital Utilization Patient Safety Goals Case Reviews Pharmacy and Therapeutics (Adverse drug reactions, do not use abbreviations)

Patient Safety Goals 2008 1. 2. 3. 4. Improve the accuracy of patient identification. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of health care-associated infections.

Patient Safety Goals 5. Accurately and completely reconcile medications across the continuum of care. 6. Reduce the risk of patient harm resulting from falls. 7. Encourage patients’ active involvement in their own care as a patient safety strategy. 8. The organization identifies safety risks inherent in its patient population.

Questions and Dialogue