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Complete Care at Kaiser Permanente: Transforming Chronic and

Preventive Care

Article  in  Joint Commission journal on quality and patient safety / Joint Commission Resources · November 2013

DOI: 10.1016/S1553-7250(13)39064-3 · Source: PubMed

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484 November 2013 Volume 39 Number 11

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The Chronic Care Model (CCM) aims to transform care forpatients with chronic illnesses through six interrelated sys-

tem changes: health system, delivery system design, decision sup-port, clinical information systems, self-management support,and community resources.1–3 It has stimulated innovative modelsof primary care redesign, including the patient-centered medicalhome.4–7 Many health care organizations have used the CCM toguide care improvements for conditions such as diabetes,asthma, and congestive heart failure.8 However, the quality im-pact of large-scale redesign implementing system changes acrossconditions and extending them into wellness and preventive carehas been much less frequently reported.9 In addition, little hasbeen reported on redesign spanning settings outside of primarycare and entailing increased collaboration between all health careteam members to provide person-focused, evidence-based care.

In 2004 senior leaders in the Kaiser Permanente SouthernCalifornia (KPSC) region, where approximately 6,000 physi-cians in the Southern California Permanente Medical Groupprovide care to 3.5 million adult and pediatric members in 13medical centers and 200 medical office buildings, recognizedthat performance was below what they aspired to achieve. Forinstance, among 34 Healthcare Effectiveness Data and Informa-tion Set (HEDIS) measures,10 KPSC performance was above thenational 90th percentile on 15 measures but fell between the50th and 90th national percentiles on 8 and below the national50th percentile on 11.

Beginning in 2005 the KPSC regional leadership identifiedseveral system opportunities to improve care. Population-basedcare management programs for chronic conditions were siloed,with separate staff, work flows, decision support, and tactics.Start-up time for new condition-specific programs typically tookmany months to a year, despite elements common to all, suchas outreach, point-of-care decision support, reporting tools,health education programs, and patient use of Kaiser Perma-nente’s online patient portal, kp.org.11 KPSC leaders also iden-tified opportunities to support evidence-based care in new ways,

Michael H. Kanter, MD; Gail Lindsay, RN, MA; Jim Bellows, PhD; Alide Chase, MS

Organizational Change and Learning

Complete Care at Kaiser Permanente: Transforming Chronic andPreventive Care

Article-at-a-Glance

Background: In 2004 Kaiser Permanente Southern Cali-fornia (KPSC) recognized the potential to improve the qual-ity of care. Healthcare Effectiveness Data and InformationSet (HEDIS) performance was below what regional leader-ship aspired to achieve, exceeding the 90th national per-centile on only 15 of 34 measures. Beginning in 2005regional leadership identified several system opportunitiesto enhance evidence-based, person-focused care.Development of Complete Care: KPSC developed andimplemented a comprehensive delivery system redesign andexpanded and integrated existing clinical information sys-tems, decision support, work flows, and self-managementsupport—collectively referred to as Complete Care. The goalof Complete Care is to transform care for healthy members,those with chronic conditions, and those with multiple co-morbidities. To date, KPSC has applied Complete Care to26 chronic conditions and areas of preventive and wellnesscare. Implemented in all care settings and optimizing theroles of all health care team members to maximal scope ofpractice, Complete Care provides evidence-based, person-focused care addressing a large set of protocol-based healthneeds for every individual during every encounter within thehealth care system. Results: On 51 HEDIS metrics, KPSC improvementusing Complete Care averaged 13.0%, compared with 5.5%improvement in the national HEDIS 50th percentile. Conclusion: Implementation of Complete Care at KPSCwas followed by six-year quality gains that outpaced changesin the HEDIS national percentiles for many measures. Ad-ditional care gaps have been included in proactive office en-counter checklists; these relate to elder care, advancedirectives, posthospital care, immunizations, health mainte-nance, and pregnancy care.

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including increasing screening rates and ap-propriate follow-up, improving medicationadherence, and avoiding potentially harmfulmedication interactions.

In addition, members sometimes arrivedat the point of care with evidence-based careneeds in addition to presenting needs, butthe former were not consistently addressed.For example, in 2004 more than 47,000members were overdue for a mammogram,and 10,530 were overdue for a glycosylatedhemoglobin (A1c) test; of these, 62% and63%, respectively, presented in specialtycare clinics where these evidence-based careneeds were not addressed. Finally, KaiserPermanente primary care providers (PCPs)were working at full capacity, sometimesdoing tasks that did not require a physician’sexpertise. KPSC leaders saw an opportunityto fully leverage team-based care andthereby enable all members of the healthcare team to work to maximal scope of prac-tice to enhance care.

Consequently, KPSC developed and im-plemented delivery system redesign and ex-panded and integrated existing clinicalinformation systems, decision supports,work flows, and self-management sup-port—collectively identified as “CompleteCare” in 2009, which has been appliedacross a growing portfolio of conditions andprevention needs (Figure 1, right).

The goal of Complete Care is to trans-form care for every individual in our population: healthy mem-bers, those with chronic conditions, and those with multiplecomorbidities. It uses every encounter within the health care sys-tem and between-encounter surveillance and outreach to reliablyprovide an individually tailored set of evidence-based, protocol-driven, proactive clinical care related to wellness and preventionand subacute, acute, chronic, and complex conditions. CompleteCare is applied across ambulatory, urgent and emergency care,inpatient, continuing care, and virtual (for example, phone, e-mail, and Internet) settings. Complete Care is person-focused,allowing for better recognition of health problems and needsover time and facilitating appropriate care in the context of allof an individual’s health needs.12 In this article, we describeComplete Care in detail and assess its impact on quality of care.

What Complete Care Does Consider a patient with diagnosed diabetes, hypertension, andhyperlipidemia whose diabetes medication and testing conformto protocols. However, she does not routinely take her hyper-tension medication, and her prescribed statin has not yet loweredher cholesterol levels to the target range. If she presents in pri-mary care, her PCP notes that the chronic care summary in theelectronic health record (EHR) shows a low hypertension med-ication possession ratio and the need for the statin dose to beadjusted; accordingly, the PCP recommends treatment intensi-fication.13 Clinic support staff and her PCP address medical andbehavioral issues, such as medication adherence and physical activity.14

If this member does not present for care, because she belongs

Complete Care Conditions/Preventive Needs and Tactics, 2005–2012

Figure 1. “Complete Care,” through a variety of tactics, has been applied across a growing portfolio ofconditions and prevention needs. COPD, chronic obstructive pulmonary disease; AAA, abdominal aorticaneurysm; ED, emergency department; UC, urgent care. “Rare diseases” includes amyotrophic lateralsclerosis, Down syndrome, and spinal cord injury.

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to a population targeted for improvement, a panel manager (anRN or a pharmacist) reviews her record and refers to clinicalprotocols for treatment intensification and follow-up testing.The recommendations appear in the PCP’s electronic task listfor review and action. After PCP approval, clinic support staffcontact the patient, explain the medication change and testing,and advise her to drop by for a no-appointment blood pressurecheck. If she does not pick up the new medication and completeordered testing, she receives a pharmacy reminder by mail or se-cure messaging. Wherever her next clinical encounter occurs—in primary, specialty, or urgent care or with the telephone callcenter—providers remind her about the medication and testing.At her next primary care visit, the receptionist, medical assistant,nurse, and PCP each receive prompts tailored to their individualwork flows to address her care needs.

CLINICAL COMPONENTS OF COMPLETE CARE

Table 1 (right) summarizes the clinical components of Com-plete Care: proactive team-based care in all settings, supplemen-tal tactics, and health information technology.

PROACTIVE TEAM-BASED CARE IN ALL SETTINGS

At every point of care, KPSC providers address members’presenting needs, chronic and complex conditions care, andscreening, preventive, and wellness care. Providers respond toall needs during the same encounter when possible or order in-dicated protocol-based care. Addressing all presenting needs,chronic and complex conditions care, and screening, preventive,and wellness care during encounters could exceed the time avail-able for care and overwhelm providers.15–17 To avoid overbur-dening physicians, KPSC reengineered routine office visits intothe proactive office encounter,18 in which all health care teamproviders—physicians, receptionists, medical assistants, andnurses—address identified patient needs within their scopes ofpractice, improving the consistency of preventive care, qualityof chronic conditions care, and reliability of staff support forphysicians. Support staff use electronic checklists customized toeach patient to proactively identify “care gaps”—indicated pro-tocol-based chronic and preventive care that patients have notyet received—and use defined protocols and work flows withintheir scopes of practice to help physicians close them. All healthcare providers use centrally standardized, diagnosis-specific workflows before, during, and after office encounters (Figure 2, page487).

Because patients with unmet screening needs were frequentlyseen only in specialty care, specialty departments also addresspreventive screening and chronic care needs using the proactive

office encounter. Physician leaders brokered an agreement be-tween primary care and specialty care departments that deter-mined which care gaps specialty care would address and specifiedthat primary care would continue to manage medications andabnormal lab findings. After proactive encounter work flowswere extended in 2009 into emergency and urgent care depart-

Proactive Proactive encounters

team-based ■ Preencounter assessment targets care gaps;

care in all support staff contact patient to address them.

settings ■ During encounter, nurses and medical

assistants follow standardized work flows and

care gap assessment/closure processes.

■ Postencounter, patients receive information

needed to take next steps: after-visit summary,

instructions, follow-up appointments, and

referrals.

Supplemental Panel management

tactics ■ Team supports primary care physician in

managing entire patient panel by identifying pa-

tients with key care gaps and supporting actions

to close them.

Care/case management

■ Supports patients who need longer-term, more

intensive support (for example, patients with

complex chronic conditions, special needs,

end-stage renal disease, heart failure, HIV)

Health education and wellness, wellness coaching

■ Supports patients’ self-care and self-efficacy by

providing in-person group classes and telephonic

coaching

Outreach

■ Conducted centrally at region and at medical

centers via telephone, secure messaging, mail

Regional safety net

■ Ensures proper follow up for selected diagnos-

tic tests, monitoring of selected medications, and

avoidance of potentially harmful interactions

Medication adherence

■ Clinicians are trained to identify barriers to ad-

herence and offer solutions to help patients use

medications correctly.

■ Patients with overdue refills or low adherence

for certain medications receive outreach.

Health Clinical information systems and decision support

information ■ Real-time laboratory, radiology, pharmacy,

technology and other clinical data available to providers

■ Point-of-care best practice alerts

Quality and performance reports

Online patient portal, kp.org*

* Kaiser Permanente. My Health Manager. Accessed Sep 23, 2013.

https://healthy.kaiserpermanente.org/health/care/consumer/my-health

-manager.

Table 1. Clinical Components of Complete Care

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ments and in 2010 into the inpatient setting, pharmacies, andcall centers, they remain in place in all settings. The entire KPSChealth care team “owns” the population of all members.

SUPPLEMENTAL TACTICS OUTSIDE THE PROACTIVE

OFFICE ENCOUNTER

Even with the proactive office encounter supporting Com-plete Care, optimizing care requires additional tactics (Table 1).Not all care gaps can be closed during encounters, and some pa-tients with care gaps do not initiate health care encounters. Inaddition, some tactics require specialized skills.

Proactive supplemental tactics are provided by staff at medicalcenters or at a centralized regional location. Medical center staffprovide patient panel management, a set of tools and processesfor population care applied systematically at the level of primarycare practices.19–21 Regional leadership identifies a target popu-lation for which a need for improvement exists; examples includepatients with diabetes and hemoglobin A1c levels > 9.0% or pa-tients needing a PCP appointment with low-density lipoproteincholesterol (LDL-C) levels > 100. Working with integrated dis-ease registries, panel management staff members review chartsof high-risk patients within physician panels, identify opportu-nities to align care with evidence-based guidelines, and initiateprotocol-based orders for tests or medication changes. Treatingphysicians review drafted orders—approving them or choosinga different course of action—and arrange for clinical or panelmanagement staff to contact patients. More than 300 care man-

agers at the medical centers also provide care and case manage-ment for members who need additional support.

All medical centers offer health education and wellness pro-grams on topics such as diabetes, heart health, stress reduction,depression, weight management, senior health and aging, andtobacco cessation. Point-of-care decision support identifiesmembers as candidates for health education, in which physi-cians, panel management staff, and office staff strongly encour-age participation. Patients receive no financial incentives forparticipation. Telephone wellness coaching helps members sethealthy goals and create strategies to achieve them for tobaccocessation, weight management, physical activity, healthy eating,and stress management. Members can also access health andwellness programs on kp.org.11

Centralized regional staff provide outreach through securemessaging, letters, and phone calls related to chronic diseasemanagement and screening, immunizations, cancer screening,and ordered but incomplete laboratory tests. Staff conduct out-reach once per year for each patient with a particular care gap;patients with multiple care gaps receive separate outreach con-tacts, although all needed tests can be completed in a single tripto the laboratory. If patients do not respond to outreach, proac-tive office encounters or panel management (if they belong toan identified target population) address care gaps.

A centralized regional safety net team ensures proper follow-up for all KPSC members for certain diagnostic and screeningtests (for example, elevations of creatinine and prostate-specific

Summary of Proactive Office Encounter

Figure 2. All health care providers use centrally standardized, diagnosis-specific work flows before, during, and after office encounters. A1c, glycosylated hemoglobin;LDL-C, low-density lipoprotein cholesterol.

Preencounter

Proactive Identification

■ Identify missing labs (A1c, LDL-C, microal-

bumin), screening procedures, access man-

agement, kp.org status, etc.

■ Provide member instructions prior to visit

■ Contact member and document encounter

in HealthConnectTM

During Encounter

Office Encounter Management

■ Preencounter follow-up

■ Vital signs, history, social, demographics,

medication review

■ Identify and flag alerts for provider for

screening and uncontrolled chronic conditions

■ Room and prepare patient for necessary

exams

Postencounter

Immediate:

■ After-visit summary, after-care instructions,

follow-up appointments, health ed materials,

how to access information on kp.org

Future:

■ Follow up contact and appointments per

provider

Proactive Office Support

Phone callsE-mailsLetters

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antigen [PSA], positive fecal occultblood testing, abnormal Papsmears), monitors selected medica-tions (for example, anticonvulsants,digoxin, angiotensin-converting en-zyme inhibitors [ACE-Is] or an-giotensin II receptor blockers[ARBs]), and identifies potentiallyharmful medication interactions(for example, tricyclic antidepres-sants in patients with dementia).22

The safety net team notifies treatingproviders about test results outsidethe laboratory normal range and in-forms them about all missed opportunities to follow up; treatingproviders use clinical judgment re-garding the necessity for follow-upcare. Centralized regional pharmacystaff also use medication adherencetactics, including automated refillreminder calls and contactingmembers with overdue refills for orlow adherence to certain medica-tions (for example, statins, diabetesmedications, beta-blockers, ACE-I/ARBs, lisinopril/hydrochlor-thiazide).

Regional outreach can be rapidly implemented and highlyspecific. For example, within 24 hours of a substantial deterio-ration in air quality from large brush fires in August 2009, KPSCsent automated phone calls about appropriate precautions to ap-proximately 280,000 members with asthma who lived in the af-fected areas.

HEALTH INFORMATION TECHNOLOGY’S PROMPTING

AND TRACKING OF ALL NEEDED CLINICAL ACTIONS

KP HealthConnectTM, Kaiser Permanente’s EHR, providesreal-time information about care for individual patients and, likeother EHRs, is optimized to support individual clinical encoun-ters. To meet our population-based goals of tracking and address-ing patients’ care gaps across settings, we also use PermanenteOnline Interactive Network Tools (POINT), a comprehensiveregional set of registries. Beginning in the late 1990s POINTwas internally developed to identify members with specific con-ditions and care gaps and to support activities such as pharmacy-based medication titration. It integrates clinical data frommultiple sources (for example, laboratory results, pharmacy,

patient encounters) and supports the execution of complex algorithms with multiple contingencies. Algorithms run contin-uously on all clinical data to identify care gaps. Every patient’sinformation, updated daily, appears in a set of linked tools, asfollows:

■ A chronic care summary sheet providing at-a-glance infor-mation about chronic conditions treatment and monitoring

■ Point-of-care alerts and prompts for all team members (Fig-ure 3, above)

■ Stratified outreach and follow-up lists Health information technology also supports self-manage-

ment. Patients receive detailed after-visit summaries containingkey information, reminders, and instructions, and kp.org pro-vides secure patient-provider messaging, access to medicalrecords, extensive health information, and care reminders. Useof secure messaging between KPSC patients and physicians wasassociated with improved quality of care for chronic conditions.23

In 2012 KPSC members made more than 25 million visits tokp.org, viewing laboratory results 11 million times, sendingmore than 3 million e-mails to their providers, refilling 4 millionprescriptions, and reviewing information from previous visitsmore than 4 million times.

Proactive Encounter Checklist in KP HealthConnect

Figure 3. The Proactive Encounter Checklist provides point-of-care alerts and prompts for all team members.

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LEADERSHIP AND ADMINISTRATIVE STRUCTURE

Under the oversight of the Southern California PermanenteMedical Group, the infrastructure of Complete Care includesleadership and administrative support. Regional leaders identifyand prioritize opportunities to better align care with evidence-based guidelines and set annual performance targets using na-tional benchmarks, such as HEDIS 90th percentiles or top-tenperformance in the United States on the National Committeefor Quality Assurance Quality Compass.24

A team of regional staff and clinical experts identifies strategyand resources required to meet targets. Regional clinical and ad-ministrative leaders review the strategy and map needed tacticsonto the Complete Care clinical components.

A small regional team has oversight and accountability forimplementing Complete Care across sites and conditions. Re-gional leads for each condition support medical centers. Physi-cian and administrative Complete Care leaders andcondition-specific champions at medical centers work to imple-ment identified tactics. As they apply Complete Care to newconditions and preventive needs, regional staff and implemen-tation leaders track the rollout across settings and monitor to en-sure sustainability of components over time for all conditions.Medical centers receive monthly performance data.

Biannual meetings of physician and administrative conditionchampions allow them to share successful practices and brain-storm new ideas. Leaders also celebrate successes and engageproviders and staff with compelling stories. For instance, videoethnography and patient stories conveyed early examples ofComplete Care to providers and staff, fueling the collective willfor change.25

Deploying Complete Care components required minimal in-vestment in personnel. Nurses reassigned from decommissionedcondition-specific programs largely staffed new centralized tac-tics, and Complete Care functions were embedded in work flowsfor existing staff. For example, existing pharmacy staff imple-mented centralized pharmacy counseling on medication adher-ence. However, developing business information systems andPOINT registries to augment the EHR required investment.

Complete Care in ActionComplete Care applies to all KPSC members; no enrollment isrequired. It operates in approximately 20 million annual ambu-latory care visits, but much of Complete Care takes place outsideof the office visit setting. In 2012 KPSC members experiencedapproximately 7 million outreach contacts, of which 82% oc-curred by mail, 16% by phone, and 3% by e-mail. KPSC“touches” approximately 88% of members through Complete

Care each year; 61% of members receive 2 to 4 contacts. In 2012more than 13,000 patients were newly enrolled in care or casemanagement services lasting two months or more, which in-cluded more than 1.86 million interactions by mail, e-mail, tele-phone, and in person. Patients made more than 300,000 onlineand in-person visits to health education and wellness programs.

By the end of 2012 KPSC applied Complete Care to 25 con-ditions and preventive needs (Figure 1). Initially targeting adultchronic conditions and preventive needs, KPSC subsequentlyexpanded into pediatrics, obstetrics/gynecology, and less com-mon conditions. Most recently, Complete Care was applied torare diseases (amyotrophic lateral sclerosis, Down syndrome, andspinal cord injuries), abdominal aortic aneurysms, and hospitalreadmissions.

Addressing new conditions or additional care gaps is a matterof mapping them to the most appropriate Complete Care com-ponents, which can be adapted to any condition and exist at suf-ficient scale to support all Complete Care goals. Applyingstandard processes across conditions reduces the complexity ofproviding care management, a barrier to success.26 As we notedearlier, it also reduces the amount of time required to begin pro-viding Complete Care for a new condition.

In addition, clinical leaders for each condition and at eachmedical center need no detailed tactical expertise in, for instance,conducting outreach; with the Complete Care infrastructure inplace, they can focus on condition-specific clinical care and bestpractices.

With providers addressing all care needs at every encounter,we anticipated that Complete Care would reduce gaps betweenrecommended and received care. It was impracticable to assignsome providers or patients to usual care because of the region-wide implementation of Complete Care over a long time frame.Our retrospective observational assessment used a pre-post de-sign and nationally benchmarked measures to assess KPSC qual-ity of care over time.

Evaluating Improvement with Complete CareTo evaluate the effect of Complete Care on quality of care, wecompared improvement in KPSC HEDIS performance frombaseline to 2012 (2011 data) with improvement in national av-erage HEDIS performance (50th percentile across all reportinghealth plans) for 51 chronic and preventive care measures incommercial and Medicare populations. We defined each baselineas the year before application of Complete Care or the earliest year for which trendable HEDIS benchmark data areavailable.

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RESULTS

Using Complete Care, KPSC improvement from baseline av-eraged 13.0% across 51 HEDIS metrics, compared with 5.5%improvement in the national HEDIS 50th percentile. KPSC improvement from baseline averaged 12.8% across 26 HEDISmetrics in the Medicare population, compared with 5.4% im-provement in the national HEDIS 50th percentile (Figure 4,above). Kaiser Permanente Southern California improvementfrom baseline averaged 13.3% across 25 HEDIS metrics in thecommercial population, compared with 5.6% improvement inthe national HEDIS 50th percentile (Figure 5, page 491).

KPSC’s improvement from baseline ranged from 2.0 to 60.3percentage points and exceeded national improvement by > 5

percentage points for 28 of 51 measures. For the remaining 23measures, KPSC’s improvement was within 5 percentage pointsof national improvement for 12 measures and lagged behind na-tional improvement in terms of percentage points for 11 mea -sures. KPSC’s performance on 7 of the latter measures exceededthe national HEDIS 90th percentile at baseline and in 2012.Baseline KPSC scores were at or above the national HEDIS 90thpercentile in 21 measures. KPSC’s 2012 HEDIS performancewas at or above the national HEDIS 90th percentile in 41 measures.

DiscussionComplete Care has been successfully implemented across 25

Improvement at Kaiser Permanente Southern California Relative to Changes in Healthcare Effectiveness Data and Information Set (HEDIS) National Percentiles,

Medicare Population, Baseline–2012

Figure 4. Kaiser Permanente Southern California improvement from baseline averaged 12.8% across 26 HEDIS metrics in the Medicare population, comparedwith 5.4% improvement in the national HEDIS 50th percentile. COPD, chronic obstructive pulmonary disease; LDL-C, low-density lipoprotein cholesterol;HbA1c, glycosylated hemoglobin; MI, myocardial infarction.

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conditions and preventive needs among KPSC’s members andis associated with improvements in HEDIS effectiveness-of-caremeasures. A strength of our assessment is its application to abroad range of HEDIS effectiveness-of-care measures, spanningchronic, acute, and preventive care needs.

Few reports exist of systems-level quality improvements acrossmultiple chronic, acute, and preventive health care needs. Jha etal. assessed the effect of systemwide reengineering on quality ofcare in the US Department of Veterans Affairs (VA) health caresystem.9 They compared 17 quality-of-care indicators before andafter reengineering and compared 11 similar indicators with the

Medicare fee-for-service program. For the 9 indicators for whichdata were consistently available, quality of care improved, andthe VA outperformed Medicare on all indicators except one. Incontrast, in comparing our performance over 26 HEDIS effec-tiveness-of-care indicators in the Medicare population and 25 inthe commercial population, we found that our performance im-provement outpaced improvement in the national HEDIS 50thpercentile by > 5 percentage points for 28 of 51 measures andby < 5 percentage points for another 12 measures.

Limitations to our assessment of the impact of CompleteCare include the absence of a control or comparison group; as-

Improvement at Kaiser Permanente Southern California Relative to Changes in Healthcare Effectiveness Data and Information Set (HEDIS) National Percentiles,

Commercial Population, Baseline–2012

Figure 5. Kaiser Permanente Southern California improvement from baseline averaged 13.3% across 25 HEDIS metrics in the commercial population, comparedwith 5.6% improvement in the national HEDIS 50th percentile. LDL-C, low-density lipoprotein cholesterol; COPD, chronic obstructive pulmonary disease;HbA1c, glycosylated hemoglobin; MI, myocardial infarction.

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signing patients or providers to a usual care alternative was notfeasible because Complete Care was implemented throughoutKPSC. In addition, we implemented Complete Care in an inte-grated delivery system with a comprehensive EHR and addi-tional registries. Although individual components, such as theproactive office encounter, could be implemented in other set-tings, the generalizability of the entire redesign is unknown. Thereasons why some HEDIS measures did not show comparableimprovement are unknown. Finally, we did not attempt to assessthe impact of Complete Care on costs or utilization.

Comparison of KPSC’s improvement with national HEDISperformance reduced the possibility that the improvements wenoted reflected large secular trends. Other potential explanationsfor the reported findings include provider financial incentives toimprove quality of care. Although KPSC provider compensationhas long included financial incentives for quality performance,incentive structures remained unchanged over the time perioddescribed here, and the amount was modest. As we noted earlier,staffing levels remained essentially unchanged as we redirectedexisting resources, and the capacity to address all patient needscame from all members of the health care team operating at fullscope of practice.

The most challenging aspect of implementing Complete Carewas the required culture change. For instance, KPSC regionalleadership created goals for specialty chiefs related to addressingagreed-on care gaps, but the first year or two of the program sawlittle progress, which may have reflected resistance related to thetime required and the use of standardized work flows. Regionalleadership then began measuring and reporting care gaps at thedepartment level, using a “missed opportunities report” to indi-cate the percentage of patients’ specialty care visits for which pre-senting needs were left unaddressed. In addition, a nominalfinancial incentive was attached to departmental performancegoals.

Existing outreach was a patchwork of efforts, with individualemployees responsible for specific conditions and medical cen-ters but without backup when employees took sick or vacationdays, thereby undermining outreach effectiveness. It became ev-ident that centralized outreach would be substantially more re-liable, and employees turned their outreach responsibilities overto the regional program. Transparency about outreach effortswas pivotal to culture change. Complete Care staff (1) documentall regional outreach attempts in the EHR where PCPs and otherclinical staff view them and (2) update physicians about outreachimpact at the population level, such as the response rates to letters.

Similarly, shifting from existing condition-specific care and

case management programs to Complete Care also required achange in organizational culture. Personnel with responsibilityfor existing programs hesitated to trust regionally standardizedprograms to provide the same level of care. In addition, physi-cians were accustomed to simple “referral and report” arrange-ments; for example, PCPs referred patients to a diabetes caremanagement program and received reports when they were dis-charged. Again, changing the culture required communicationand transparency. Many physicians noted that their confidencein Complete Care grew as they saw HEDIS and other qualitymetrics improve. By January 2013 physician co-sign rates for re-gional safety net recommendations exceeded 90%. Sidebar 1(page 493) provides an example of how implementation oc-curred through culture change at a single medical center.

CONTINUING ENHANCEMENTS AND FUTURE

DIRECTION

The regional safety net currently includes 15 evidence-basedscreening, diagnostic, and follow-up protocols and 12 medica-tion monitoring protocols. Additional care gaps have been in-cluded in proactive office encounter checklists; these relate toelder care, advance directives, posthospital care, immunizations,health maintenance, and pregnancy care. KPSC has begun en-hanced population- and/or condition-specific outreach effortsto address disparities in health care, beginning with outreach toAfrican American members with uncontrolled hypertension. Tomake outreach in general more efficient and support greater pa-tient activation, a Patient Action Plan became available in De-cember 2012 to all members through kp.org; it includesindividualized and up-to-date information on cancer screenings,preventive care, health care, chronic health conditions and med-ications, immunizations, and general guidelines. Nine monthsof experience has shown that patients who visit the Patient Ac-tion Plan address care gaps at a high rate. Areas in need of furtherrefinement include customizing outreach to optimize responserates, such as tailoring the frequency and type of contact (for ex-ample, mail, automated phone call, secure message) to patients’individual preferences. In addition, KPSC is expanding intousing technology in new ways to support Complete Care, suchas in mobile outreach messaging.

ConclusionsThe regional safety net provided by the Complete Care programat KPSC includes 15 evidence-based screening, diagnostic, andfollow-up protocols and 12 medication monitoring protocols.Implementation of Complete Care at KPSC was followed byquality gains that outpaced changes in the HEDIS national per-

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In 2005 Kaiser Permanente San Diego Medical Center initiated popu-

lation-based care management programs for conditions such as

asthma, diabetes, and heart failure. Run by a separate population-

based management department, these programs were siloed from

primary and specialty care. In 2008 a new administrative team for the

medical center recognized that performance was the lowest in the

Southern California region on nine Healthcare Effectiveness Data

and Information Set (HEDIS) preventive and chronic care measures

(even though it was above the national 90th percentile on six and

within three percentage points of the national 90th percentile on the

others). In early 2010 new physician and administrative leads for

Complete Care were hired at the medical center.

Regional data on departmental performance identified clear opportu-

nities for improvement, and senior leadership placed top priority on

establishing a collaborative culture for addressing quality goals. After

consulting with regional experts, senior leaders applied successful

Complete Care components. They asked clinical champions to self-

select for being accountable for addressing improvement opportuni-

ties; in most cases, champions were specialty department heads.

Senior leaders made sure that the Complete Care leads were on the

agendas of multiple leadership meetings, where they consistently

communicated the importance of a collaborative approach to quality

improvement. The Complete Care Team spread its theme, “All Hands

In,” to establish the importance of every member of the health care

team to the health of every patient they encountered.

The new Complete Care leads played a consultative role, helping

providers identify how everyone on the health care team could act to

meet quality goals. Starting with simpler examples—such as mam-

mography and colorectal cancer screening—made it easier for sup-

port staff to understand their role in ensuring that all patients received

all the care they needed every time they came in contact with the

health care system. For example, an orthopedic surgery medical as-

sistant checking in a patient for follow-up of an acute injury would

also remind the patient that she needed a mammogram and offer to

schedule it. Work on more complex care processes followed.

Complete Care leads also talked to all stakeholders for particular

measures to identify systems issues. In one instance, the clinical lab-

oratory reported that every month, stool samples for colorectal cancer

were often discarded because of illegible labeling by patients. A sim-

ple fix was to ensure that sample containers were labeled before dis-

tribution to patients. The leads also discovered coding issues

affecting reported performance.

Clinical champions provided messaging pertaining to their area of

care. For example, an orthopedic surgeon promoted Healthy Bones,

an osteoporosis management initiative, among his peers. A nephrolo-

gist spurred his colleagues to improve chronic kidney disease

through control of cholesterol and to support the Healthy Bones pro-

gram. Champions were also accountable to senior leaders for per-

formance throughout the service area on their measures. In 2010 and

2011 clinical champions received performance data on a weekly

basis, as did senior leaders who recognized improvement and asked

questions about the lack thereof.

Throughout 2011, monthly “Guinness World Record”’ meetings

events provided motivation to prevent chronic diseases and to save

more lives. Transparent data on individual medical office building

quality measures were shared throughout the service area. Competi-

tion between buildings and departments helped motivate improve-

ment. Between May 2010 and June 2012 performance on selected

HEDIS measures improved by 1.0 to 8.6 percentage points (seetable, below). San Diego’s regional rank improved from 13 of 13

medical centers on nine chronic and preventive care measures to

between 2nd place (two measures) and 10th place (two measures).

Sidebar 1. Case Study: Complete Care in San Diego

Performance of Kaiser Permanente San Diego Medical Center on HEDIS Measures, May 2010 and June 2012*

Measure May 2010 June 2012

Colorectal cancer screening 69.1% 77.7%

Breast cancer screening 87.3% 88.3%

Cervical cancer screening 85.2% 86.7%

Diabetes: HbA1c < 9 79.7% 82.4%

Diabetes: HbA1c < 8 66.0% 70.5%

Diabetes: HbA1c screening 94.0% 95.1%

Diabetes: LDL-C < 100 61.6% 65.8%

Cardiovascular disease: LDL-C < 100 69.8% 77.7%

Blood pressure control in hypertension 81.5% 86.0%

* HEDIS, Healthcare Effectiveness Data and Information Set; HbA1c, glycosylated hemoglobin; LDL-C, low-density lipoprotein cholesterol.

Copyright 2013 © The Joint Commission

494 November 2013 Volume 39 Number 11

The Joint Commission Journal on Quality and Patient Safety

centiles for most of the measures. Complete Care provides anexample of using core components to provide reliable and scal-able health care across 25 conditions and preventive needs.

The authors thank Rae Boganey, MD, and Yvonne Plowman, who provided San

Diego’s experience with Complete Care for the case study. Jenni Green provided

editorial assistance.

References1. Wagner EH, Austin BT, Von Korff M. Organizing care for patients withchronic illness. Milbank Q. 1996;74(4):511–544.2. Wagner EH. Chronic disease management: What will it take to improve care

for chronic illness? Eff Clin Pract. 1998;1(1):2-4.3. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for pa-tients with chronic illness. JAMA. 2002 Oct 9;288(14):1775–1779.4. Graf TR, et al. Value-based reengineering: Twenty-first century chronic caremodels. Prim Care. 2012;39(2):221–240.5. Iglehart JK. No place like home: Testing a new model of care delivery. NEngl J Med. 2008 Sep 18;359(12):1200–1202.6. Bodenheimer T. Coordinating care: A perilous journey through the healthcare system. N Engl J Med. 2008 Mar 6;358(10):1064–1071.7. Patient-Centered Primary Care Collaborative (PCPCC). Joint Principles ofthe Patient-Centered Medical Home. Washington, DC: PCPCC, Feb 2007. Accessed Sep 23, 2013. http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf.8. Coleman K, et al. Evidence on the Chronic Care Model in the new millen-nium. Health Aff (Millwood). 2009;28(1):75–85.9. Jha AK, et al. Effect of the transformation of the Veterans Affairs HealthCare System on the quality of care. N Engl J Med. 2003 May 29;348(22):2218–2227.10. National Committee for Quality Assurance. HEDIS & Performance Mea -surement. Accessed Sep 23, 2013. http://www.ncqa.org/HEDISQualityMeasurement.aspx.11. Kaiser Permanente. My Health Manager. Accessed Sep 23, 2013.https://healthy.kaiserpermanente.org/health/care/consumer/my-health-manager.12. Starfield B. Is patient-centered care the same as person-focused care? PermJ. 2011;15(2):63–69.13. Halpern MT, et al. Recommendations for evaluating compliance and per-sistence with hypertension therapy using retrospective data. Hypertension.2006;47(6):1039–1048.14. Coleman KJ, et al. Initial validation of an exercise “vital sign” in electronicmedical records. Med Sci Sports Exerc. 2012;44(11):2071–2076.15. Østbye T, et al. Is there time for management of patients with chronic dis-eases in primary care? Ann Fam Med. 2005;3(3):209–214.16. Pollak KI, et al. Estimated time spent on preventive services by primarycare physicians. BMC Health Serv Res. 2008 Dec 1;8:245.17. Yarnall KS, et al. Primary care: Is there enough time for prevention? Am JPublic Health. 2003;93(4):635–641.18. Kanter M, et al. Proactive office encounter: A systematic approach to pre-ventive and chronic care at every patient encounter. Perm J. 2010;14(3):38–43.19. Feldstein AC, et al. Effect of a patient panel-support tool on care delivery.Am J Manag Care. 2010 Oct 1;16(10):e256–266.20. Zhou YY, et al. Improving population care with an integrated electronicpanel support tool. Popul Health Manag. 2011;14(1):3–9.21. Neuwirth EB, et al. Understanding panel management: A comparativestudy of an emerging approach to population care. Perm J. 2007;11(3):12–20.22. National Patient Safety Foundation. Building an Integrated OutpatientSafety Program. Webcast (membership required). Kanter M, Smith A. Aug 21,2012. Accessed Sep 23, 2013. http://www.npsf.org/npsf-offers/integrated-outpatient-safety-program/.23. Zhou YY, et al. Improved quality at Kaiser Permanente through e-mail be-tween physicians and patients. Health Aff (Millwood). 2010;29:1370–1375.24. National Committee for Quality Assurance. Quality Compass. AccessedSep 23, 2013. http://www.ncqa.org/tabid/177/default.aspx.25. Neuwirth EB, et al. How Kaiser Permanente uses video ethnography of pa-tients for quality improvement, such as in shaping better care transitions. HealthAff (Millwood). 2012;31(6):1244–1250.26. Brandt S, Hartmann J, Hehner S. How to design a successful disease-man-agement program. McKinsey Quarterly. 2010 Oct. Accessed Sep 23, 2013.http://www.mckinsey.com/insights/health_systems_and_services/how_to_design_a_successful_disease-management_program.

J

Michael H. Kanter, MD, is Medical Director of Quality and Clinical

Analysis, Southern California Permanente Medical Group, Pasadena,

California; and Gail Lindsay, RN, MA, is Managing Director of Clinical

Program Development. Jim Bellows, PhD, is Senior Director of Eval-

uation and Analytics, Kaiser Permanente Care Management Institute,

Oakland, California. Alide Chase, MS, is Senior Vice President, Na-

tional Medicare Clinical Operations and Population Care, Kaiser

Foundation Health Plan, Inc., Oakland, California. Please address

correspondence to Michael H. Kanter, Michael.H.Kanter@kp.org.

VA Patient Safety FellowshipThe VA National Center for Patient Safety,in cooperation with the VA Office of Academic Affiliations is pleased to offer afellowship opportunity in Patient Safety be-ginning July 2014. The fellows are based atone of seven VA Medical Center sites: AnnArbor, MI; Indianapolis, IN; Lexington, KY;Philadelphia, PA; Pittsburgh, PA; Tampa,

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EOE

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