knowledge into care… and care into knowledge
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Knowledge Into Care… and Care into Knowledge. Winston F. Wong, MD Clinical Director, Community Benefit, Natl. Program Off. Care Management Institute Kaiser Permanente. “ Lessons from L. Frank Baum ”. The Wisconsin Council on Children Madison, Wisconsin October 28, 2005. - PowerPoint PPT PresentationTRANSCRIPT
Knowledge Into Care… and Care into Knowledge
Winston F. Wong, MDClinical Director, Community Benefit, Natl. Program Off.Care Management InstituteKaiser Permanente
The Wisconsin Council on ChildrenMadison, WisconsinOctober 28, 2005
“Lessons from
L. Frank Baum”
2
Healthcare’s “Middle Space”…An Innovation Mother Lode
3
Healthcare’s “Middle Space”…An Innovation Mother Lode
4
CMI Networks – Distributed Learning and Knowledge Exchange
Implementation Network• Regionally based Physician and
Operations Oriented Implementation Experts
Analytic Network• Regionally based analysts with
local and national accountabilities Regular Inter-regional calls
• Competency and Skill Focus• Clinical Topic Focus• Improvement Accountability to
each other and to the Program Visits, Exchanges, Collaborations Annual Network Retreat
5
Kaiser Permanente America’s oldest and largest private, nonprofit,
integrated health care delivery and financing system — Founded in 1945
Multi-specialty group practice prepayment program — Headquartered in Oakland, CA
8.2 million members — 6.1 million members in California
Over 12,000 physicians representing all specialties and 130,000+ additional employees
Operations in 9 states and Washington, D.C. with 29 Medical Centers and 423 Clinics
KP Research Centers - $100,000,000 in external funding in 2003 for Health Systems Research
All employees and their families are KP members
I’ve got a feeling we’re not in Kansas anymore…
7
An estimated 37% of Kaiser Permanente’s membership is culturally diverse, compared to 31% for the U.S. population as a whole.
Latinos14.4%
African Americans
11.8%
Caucasians63.4%
Asian Americans5.5%
Other4.9%
Sources: KP demographics -- estimates by KP National Diversity Council based on 2003 data.;U.S. demographics – U.S. Census Bureau Estimates as cited in “Key Facts: Race, Ethnicity & Medical Care,” Henry J. Kaiser Family Foundation, 2003.
KP Membership Demographics 2003
8
KP Priority Conditions
Clinical Area KP Memberswith this
Condition
Asthma 141,000 (2.1% of members)
Coronary Artery Disease 256,000 (3.8%)
Depression411,000 (6.2%)
Diabetes 577,000 (8.7%)
Heart Failure 94,000 (1.4%)
(1 or more of the above 1,120,000 or 16.1% of members)
Cancer 25,000 new cases/yr
Chronic Pain ~1,000,000 (?)
Elder Care917,000
Obesity ~ 25% of adults
Self Care & Shared Decision Making 8.2 MM
9
Prevalence Within KP
Membership (2002)
Estimated Members Affected (2005)
Annual Incremental Cost ($/member/year)
(assumes 7% cost escalation rate) 2002 estimate 2005
Total Incremental
Cost ($ 2005
millions)
Asthma 2.7.% 162,843 $2,418 $2,962 $482.4 CAD 3.3% 206,234 $9,811 $12,019 $2,478.7 Depression 6.7% 557,712 $5,102 $6,250 $3,485.8 Diabetes 9.3% 584,227 $4,639 $5,683 $3,320.1 Heart Failure
1.6% 100,839 $16,134 $19,765 $1,993.1
One or More Conditions
16.1% 1,821,443
Total Incremental Cost of Chronic Conditions in “CMI Portfolio” $11,760.1
Additional Health Care Costs of Members with Chronic Conditions in “CMI Portfolio”
Source: Extrapolated from KP Northern California Division of Research estimates
10
Delivering Care…
• Process and experience oriented
• Local and tribal
• Access: to Clinicians and Visits
• Knowledge Management — Paper and Recall
• Clinician treating patients and curing acute conditions
• Outcome and knowledge oriented
• National and global
• Access: to what you need, whenever you need it
• Knowledge Management — Electrons and Judgment
• Teams — including members — managing chronic conditions
Then… Going Forward…
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Lines Between Research, Knowledge Dissemination and Implementation
Knowledge Dissemination
Implementation
Research
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Lines Between Research, Knowledge Dissemination and Implementation
Knowledge Dissemination
Implementation
Research
Information
Technology
13
If I only had a brain…
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Population Management & Levels of Care
Under the principles of population management, the first step in developing proactive strategies for the chronic conditions populations is to define their service needs. These needs generally fall into 3 service levels. Within these 3 levels, services can further be customized, at the point of care, to meet the needs of the individual member. Our goal is for the member to achieve and maintain self-management of their condition (Level 1). Members who require more assistance and monitoring would be potential candidates for Level 2 or 3 programs.
LEVEL 3 Intensive or Case Management
Leverage available resources (both Kaiser and community-based) to optimize health status and coordination of care.
LEVEL 2 Assisted Care or Care Management
Enhance self-care skills and abilities; provide clinical management using care paths and protocols.
LEVEL 1
Routine care delivered by APC Team, as well as self-management education, support for coping needs, training in the use of Health-wise Handbook, etc.
Self Care Support
Assisted Care or Care Management
Intensive or Case
Management
Prevention is part of every member’s care
Pre
vent
ion
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Level 1 Care: Achieving and Maintaining Member Self-Management
Inreach Outreach
Support Education
Clinical Management
•Helps the member achieve and maintain improved health status
•Five separate, yet interlocking components:
•Inreach
•Outreach
•Education
•Psychosocial support
•Clinical management
The components of Level 1 care
16
Asthma PopulationManagement Program
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Trends in cost ratios for members with selected chronic conditions compared to members without those
conditions, KP Northern California Region
HF CAD
Depression Diabetes
Asthma
1
2
3
4
5
1996 1997 1998 1999 2000 2001 2002 2003
Co
st
Ra
tio
18
This chart illustrates trends in the monitoring reports since 1998. The denominator for these measures is the asthma registry. An increase in the inhaled medication ratio
KPNC Adult Asthma Population Trend Data
A variety of factors, including program interventions with high risk members, may be involved in the decline in the ED visit rate.
correlates well with the decrease in Asthma-specific ED visits and hospitalizations during this period.
Northern California Asthma Monitoring Indicators, 1998-2003
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Per
ce
nt
of
pro
vid
ers
wit
h A
I ra
tio
> 0
.3
.
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
ED
Vis
its
or
Ho
spit
aliz
atio
ns
per
1,0
00 A
sth
ma
reg
istr
y m
emb
ers
Inhaled Medication 51.9% 63.3% 77.6% 84.5% 90.6% 93.40%
ED Visits 70.0 56.3 42.9 41.1 39.4 39.2
Hospitalization 10.4 7.5 5.1 5.4 5.3 6.4
1998 Q4 1999 Q4 2000 Q4 2001 Q4 2002 Q4 2003 Q4
ED Visits
Inhaled Medication
Hospitalization
19
The ratio of cost of care for members with asthma is compared to members without.
Children Adults
All costs of treating members with asthma are higher than the costs of treating members without asthma
Ratio of cost has remained the same 1996-2002
Trends in Cost Ratios
20
Does Care Management Save Money?
Substantial increases in clinical process and outcome measures have been achieved for diabetes, heart failure, coronary artery disease, asthma and depression
In 2003, these programs “saved” ~$600M relative to cost trend
These programs did not produce absolute savings – we spent more on the care of members with diabetes, heart failure, coronary artery disease, asthma and depression in 2003 than in 2002.
(Doing more and more things that are cost-effective, but not cost saving, does not save money)
These programs continue to produce absolute value
21
Is this all about chronic care? No!
Hawaii region’s Medicaid immunization rates were 92% in 2004, the 4th straight year over 90%
In 1999, the Medicaid immunization rate was 68%• RNs and allied staff review medical records and databases• Telephone outreach, then home visits• Develop patient centered messages on the importance of
immunizations, keeping appointments, and medications KP Hawaii Medicaid pediatric immunization rates
have exceeded commercial population rate by 3% since 1999…most Medicaid populations are approximately 12% lower than the commercial cohort
22
Prenatal Smoking Cessation
KP Colorado (Denver); Self reported prenatal smoking rate: 12% among commercial patients, 25% in Medicaid population
Smoking is the #1 preventable cause of perinatal morbidity and mortality, mean avg. excess direct medical cost is $511 for each prenatal pt. (live birth)
Brief cessation counseling session, followed by directed distribution of specific self help materials increases smoking cessation two fold: from 10% to 20%
23
If I only had a heart…
24
Co-morbidities are Common
25
Hospital Day Rates Among KP Members, 2001
500
1000
1500
2000
2500
Day
s p
er 1
000
mem
ber
s
Among KP Members with Diabetes
without Depression
Among KP Members with Diabetes
and Depression
Co-morbidities… impact
Among OverallKP Membership
Source: CMI 2002 Diabetes Outcomes Source: CMI 2002 Diabetes Outcomes Report Report
26
Many people fail to choose healthy Many people fail to choose healthy behaviors because they lack informationbehaviors because they lack information
One study: 76% of patients with type 2 diabetes One study: 76% of patients with type 2 diabetes received limited or no diabetes educationreceived limited or no diabetes education
50% of patients leave the medical visit without 50% of patients leave the medical visit without understanding what happenedunderstanding what happened
Minority patients receive less information than white Minority patients receive less information than white patientspatients
Clement, Diab Care 1995;18:1204. Roter and Hall, Annu Rev Publ Clement, Diab Care 1995;18:1204. Roter and Hall, Annu Rev Publ Health 1989;10:163. Stewart et al. Milbank Q 1999;77:305.Health 1989;10:163. Stewart et al. Milbank Q 1999;77:305.
27
Many people fail to choose healthy Many people fail to choose healthy behaviors because they aren’t involved in behaviors because they aren’t involved in decisionsdecisions
Study of 1000 physician visits, the patient did not Study of 1000 physician visits, the patient did not participate in decisions 91% of the timeparticipate in decisions 91% of the time
Multiple studies show that when patients are involved in Multiple studies show that when patients are involved in decisions, health-related behavior is improved and clinical decisions, health-related behavior is improved and clinical outcomes (for example HbA1c levels) are better than if outcomes (for example HbA1c levels) are better than if patients are not involvedpatients are not involved
Braddock et al. JAMA 1999;282;2313. Heisler et al. J Gen Intern Med Braddock et al. JAMA 1999;282;2313. Heisler et al. J Gen Intern Med 2002;17:243. Greenfield et al. J Gen Intern Med 1988;3:448. Golin et al. Diab Care 2002;17:243. Greenfield et al. J Gen Intern Med 1988;3:448. Golin et al. Diab Care 1996;19:1153. Piette et al. J Gen Intern Med 2003;18:624. Roter. Health Educ 1996;19:1153. Piette et al. J Gen Intern Med 2003;18:624. Roter. Health Educ Monographs 1997;5:281Monographs 1997;5:281
28
A Partnership with Measurable Outcomes
A 2002 study of results at the Pediatric Asthma Clinic of San Francisco General Hospital, a demonstration site for the “Yes We Can” clinical model, showed changes
29
High Utilizing Populations breakdown into 4 buckets:
• Frail Elderly – many diseases, many drugs, support issues, costs issues (Medicare caps), End of Life issues, different trajectories
•Substance Abuse – Alcohol and Drugs, drug seeking behavior for prescription drugs
• Psychiatric and Complex Mental Health issues (often mixed with Substance abuse and chronic pain)
• Chronic PainChronic Pain – pain medication issues
We need programs other than traditional medical model for acute and episodic care – CDRP, Chronic Pain, Outpatient Psych programs, Geriatric programs, Case management (KFH and CCC programs)
IOM report of 1/03 lists Care Coordination as one of top health care issues
High Utilizing Populations
30
How to get a Population Under Control
Traditional: Target providers and system:
Feedback, reminders, reports, guidelines, champions, academic detailing, incentives, list management
Provider gives the right med to the right patient:
Patient takes it 50% of the time
Provider gives the right self-management behavior change message (i.e. – you need to exercise, stop smoking , and lose weight)
Patient does this 10% of the time and it will probably not be sustained
It’s about adherence and concordance – how to help patient’s to succeed and sustain change not about creating dependence
31
Strengthening Member Self-Management of Chronic Conditions
Five questions critical to strengthening self-management practices:
1. What essential information, beliefs and behaviors do members need to effectively self-manage their chronic condition(s)?
2. What are the key elements and strategies to use in chronic condition self-management interventions, regardless of type of condition?
3. What are effective ways to structure the delivery of chronic condition self-management interventions in order to maximize member enrollment?
4. What are effective approaches to strengthen chronic condition self-management during the outpatient clinical encounter?
5. What are effective approaches to increase adherence to prescription medication regimens of patients with chronic conditions?
32
Associating High Performance withOperational Practices- Examples
Glycemic Screening x Action Plans
Eye Exams x AMR
Performance values shown are adjusted for all other Practices, based on model estimates
70%
75%
80%
85%
90%
0 2 4 6 8 10
Practice Score - Action Plans
Pe
rfo
rma
nc
e (
Ad
jus
ted
) -
Gly
ce
mic
Co
ntr
ol
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 2 4 6 8 10
Practice Score - Automated Medical Record
Pe
rfo
rma
nc
e (
Ad
jus
ted
) -
Ey
e E
xa
ms
33
Practices included in the analysis
Organizational Support• Leadership• Accountability• Champions• Resources• Provider Feedback• Financial Incentives• Program Evaluation
Self-Management• Action Plans• Patient Education• Integration with Care
Delivery System Design• Stratified Services• Risk Stratification• Registry• Outreach and Follow-Up• Inreach• Care Coordination• Team-Based Care• Cultural Competence
Decision Support• Guideline Distribution
and Training• Provider Alerts• Clinical Information
System
34
Associating High Performance with Operational Practices
Practices most associated with high performance• Patient action plans• Provider financial incentives• Automated medical record• Outreach and follow-up• Provider alerts and Reminders
Practices sometimes associated with performance, but with less strength and/or consistency• Registry• Guideline distribution & training• Care coordination
34
KPHealthConnect
35
Stronger implementation was associated Stronger implementation was associated with with significantsignificant performance improvement performance improvement
Average Performance of Locations in Lowest and Highest Quartile of Practice Implementation, 8 Diabetes Performance Measures Pooled, 2001-2002
45 44 45 46
38 37
6055
52
6167
60
0
10
20
30
40
50
60
70
80
FinancialIncentives
Action Plans Outreach andFollow-up
Provider Alertsand Reminders
AutomatedMedical Record
All Practices(Model)
Pe
rfo
rma
nc
e o
n A
ll M
ea
su
res
, a
s P
erc
en
tile
Locations in Lowest Quartile Locations in Highest Quartile
36
The major findings:
By comparing the level of implementation of diabetes care practices with eight diabetes performance measures, we identified five practices that were associated with better performance:
• Financial incentives• Action plans (patient-specific or personal)• Automated medical record• Outreach and follow-up• Provider alerts and reminders
37
If I only had courage. . .
38
Quality assertions …
“Poor patients don’t deserve poor care” Same care does not mean same
outcomes Quality outcomes are achieved in years,
not months Not what you do, but what you
accomplish Medicaid is about care, not payment
39
Courage to confront challenges
Faced with unprecedented financial challenges, can we implement innovative, population management approaches to improve outcomes for Medicaid populations?
Can we develop incentives for patients, providers and plans that result in improved clinical outcomes?
Can we demonstrate models of care that address the diverse cultural, linguistic, and literacy characteristics of Medicaid populations?
40
Healthcare’s “Middle Space”…An Innovation Mother Lode
41
We always had the answers
…we just didn’t know they were in our own backyard.