panel management — update and future directions robert unitan, md, kaiser permanente northwest ...
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Panel Management — Update and Future Directions
Robert Unitan, MD, Kaiser Permanente NorthwestBrian J. Lee, MD, Kaiser Permanente Hawaii
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 2
The 1:1 visit alone leaves primary care unsustainable
– Donald Berwick, MD
We Need to Do Things Differently….
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 3
Goals of Total Panel Ownership
To use evidence-based medicine to improve the health of the members we serve.
To support primary care physicians and health care teams by providing them with population care management tools and help them organize their work around KP's national priorities.
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 4
Enterprise Data Warehouse (EDW)
Claims
Membership
Ancillary
PCMCapabilities
Leverage data from KP HealthConnect to provide the backbone for panel management capabilities
Panel Management and KP HealthConnect
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 5
Panel Ownership and Complete Care
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 6
Specific Treatment Recommendations
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 7
All PST Data is Refreshed Nightly
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 8
Birthday Outreach for All Members
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 9
Sort by Contact Modality or Utilization
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 10
Monthly Performance Feedback
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 11
KPNW DM Screening—2007
HEDIS Effectiveness of Care Measure
Q4 2006 2006 HEDIS 90th Percentile
Q4 2007
DM HBA1c
Screening90.8% 92.7% 93.5%
DM LDL
Screening85.4% 85.4% 90.9%
DM Retinopathy
Screening69.6% 69.3% 75.3%
DM Nephropathy
Screening89.4% 91.2% 92.6%
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 12
A.L.L. for DM and CVD (n=45K)
Q4 2006 Target Q4 2007
ASA + Statin + Lisinopril
47.3% 50.8% 55.7%
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 13
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 14
Single Sign-On
2
Panel Support Tool Integration
Able to
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 15
Lessons Learned
Tool Development Rapid Iterative process valuable Small group that is responsible for
development, quick decisions Operational
Don’t underestimate the human factors on change—it’s only a tool
Investing in your end-users Training User feedback
Panel Management— Update and Future Directions
PART 2Brian J. Lee, MD
Kaiser Permanente Hawaii
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 17
Primary Care —Panel Management
Specialty Care — Panel Management
Primary Care — Population Management
Specialty Care — Population Management
Types of High-Level Care
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 18
Twelve PCPs, Twelve Panels
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 19
Twelve PCPs, Twelve Panels . . . Add a Disease
Red=referred Orange=unreferred
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Twelve PCPs, Twelve Panels. . . and a Specialist
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 21
Population Management—CKD at KPHI
Seeing Nephrologist—1,000
Kidney disease—15,000
Member population—210,000
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 22
Panel Management vs. Population Management
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 23
Who Needs to See a Specialist?
Those whose risk, due to a particular disease, can be substantially better managed by a specialist than a generalist.
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 24
A Change in How We Think About Referral
Specialists can judge better (vs. generalists) whom should be referred
Specialists should be more “hands-on” in deciding who makes up the subpopulation that they should be seeing
Specialists should recruit high-risk referrals, block inappropriate referrals, and send back low-risk patients to Primary Care
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 25
Panel Management vs. Population Management
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 26
Population Management
Active Management of Referrals Development of evidence base to stratify risk Solicitation of high-risk referrals Returning low-risk referrals to Primary Care
Monitor for systemic deficiencies in care Intervention without requiring referral
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 27
Population Management—Needs
Identification of need in relation to a specialty Dedicated specialist and support of department Buy in from Primary Care Time to Develop/Adapt System Population Management Tool
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 28
Identification of Need
Cardiologist—Are PCPs managing CHF on their own and if so, correctly?
Rheumatologist—are PCPs using allopurinol for patients with frequent gout attacks?
Vascular Surgeon—are there unreferred patients with large aortic aneurysms?
Can look at any lab/report, identify the extremes in the population, and determine need
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 29
Population Management—Needs
Identification of need in relation to a specialty Dedicated specialist and support of department Buy in from Primary Care Time to Develop/Adapt System Population Management Tool
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 30
Population Management Tool—Major Elements
Regular access to updated data Stratification and sorting of patients Patient-centric view Ability to review case in detail (EMR) Capacity to annotate
Integration of new data and permanent data
Message generator
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 31
Population Management Tool—Major Elements
Color coding of both Data Elements and Individual Patient Cards
“Alert” capability—warning system for acute disease, and worsening chronic disease
“Submerge” capability—hide patient cards for a specified period of time
Capability to generate statistics
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 32
Population Management Tool—Major Elements
Real-Time Lab Data Web based
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 33
Renal Population Management System
Nephrology assumes “ownership” of CKD population
Potential high-risk patients identified and examined in detail using KP HealthConnect
E-consults used as KP HealthConnect messages to PCPs
The e-consults are followed up Low risk referrals are returned to PCPs
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 34
Renal Population Management System
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 35
Population Management of CKD—Outcomes
Prevents Late Referral Improves Preparation for Dialysis Prevents Unnecessary Referral Improves Screening Rates Lowers rate of End Stage Renal Disease
Late Referral (<4 Months Prior to ESRD)
0%
5%
10%
15%
20%
25%
30%
35%
40%
KPHI 2004 KPHI 2005 KPHI 2006 KPHI 2007
Pe
rce
nt
La
te KPHI 2004
KPHI 2005
KPHI 2006
KPHI 2007
Fistula Present, Start of Hemodialysis
0%
10%
20%
30%
40%
50%
60%
2004 2005 2006 2007
Year
Pe
rce
nt
Fis tulas Present
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 41
Population Management of CKD—Anecdotal or Pending Outcomes
PCP education PCP satisfaction with Specialty Support Cost containment
© Copyright Kaiser Permanente, 2008 | For Internal Use Only National Quality & Brand Conference | Page 42
To Sum Up—Why Should a Specialist Attempt to Manage a Population of Disease?
We’re all in this together, PCPs and Specialists Can make a huge impact on quality and cost Education of our colleagues can occur in an
unusually direct and powerful way Because now, it can be done
Thank you
Questions and Discussion
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