Knowledge Into Care… and Care into Knowledge

1. 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

2. Healthcare’s “Middle Space”…An Innovation Mother Lode Sick-care Disease Management Chronic Condition Care Public Health

3. Healthcare’s “Middle Space”…An Innovation Mother Lode Sick-care MediCaid Disease Management Chronic Condition Care Public Health

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

6. 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. KP Membership Demographics 2003 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.

8. KP Priority Conditions Clinical Area KP Members with this Condition Asthma 141,000 (2.1% of members) Coronary Artery Disease 256,000 (3.8%) Depression 411,000 (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 Care 917,000 Obesity ~ 25% of adults Self Care & Shared Decision Making 8.2 MM

9. 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… Going Forward… Then… • 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

11. Lines Between Research, Knowledge Dissemination and Implementation

12. Lines Between Research, Knowledge Dissemination and Implementation Information Technology

13. If I only had a brain…

14. Population Management & Levels of Care Prevention • 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. Prevention is part of every member’s care Intensive or Case Management Assisted Care or Care Management Self Care Support

15. Inreach Outreach Clinical Management Support Education Level 1 Care: Achieving and Maintaining Member Self-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

17. Trends in cost ratios for members with selected chronic conditions compared to members without those conditions, KP Northern California Region

18. Northern California Asthma Monitoring Indicators, 1998-2003 100.0% 80.0 Inhaled 90.0% Medication 70.0 . 80.0% 60.0 70.0% ED Visits 50.0 60.0% 50.0% 40.0 Percent of providers with AI ratio > 0.3 ED Visits or Hospitalizations per 1,000 Asthma registry members 40.0% 30.0 30.0% 20.0 20.0% Hospitalization 10.0 10.0% 0.0% 0.0 1998 Q4 1999 Q4 2000 Q4 2001 Q4 2002 Q4 2003 Q4 51.9% 63.3% 77.6% 84.5% 90.6% 93.40% Inhaled Medication 70.0 56.3 42.9 41.1 39.4 39.2 ED Visits 10.4 7.5 5.1 5.4 5.3 6.4 Hospitalization KPNC Adult Asthma Population Trend Data • 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 correlates well with the decrease in Asthma-specific ED visits and hospitalizations during this period. • A variety of factors, including program interventions with high risk members, may be involved in the decline in the ED visit rate.

19. Trends in Cost Ratios 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

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. Co-morbidities… impact Hospital Day Rates Among KP Members, 2001 Among KP Members with Diabetes and Depression 2500 2000 Among KP Members with Diabetes without Depression Days per 1000 members 1500 1000 Among Overall KP Membership 500 Source: CMI 2002 Diabetes Outcomes Report

26. Many people fail to choose healthy behaviors because they lack information • One study: 76% of patients with type 2 diabetes received limited or no diabetes education • 50% of patients leave the medical visit without understanding what happened • Minority patients receive less information than white patients • Clement, Diab Care 1995;18:1204. Roter and Hall, Annu Rev Publ • Health 1989;10:163. Stewart et al. Milbank Q 1999;77:305.

27. Many people fail to choose healthy behaviors because they aren’t involved in decisions • Study of 1000 physician visits, the patient did not participate in decisions 91% of the time • Multiple studies show that when patients are involved in decisions, health-related behavior is improved and clinical outcomes (for example HbA1c levels) are better than if patients are not involved • 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 1996;19:1153. Piette et al. J Gen Intern Med 2003;18:624. Roter. Health Educ Monographs 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 • 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 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

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: • What essential information, beliefs and behaviors do members need to effectively self-manage their chronic condition(s)? • What are the key elements and strategies to use in chronic condition self-management interventions, regardless of type of condition? • What are effective ways to structure the delivery of chronic condition self-management interventions in order to maximize member enrollment? • What are effective approaches to strengthen chronic condition self-management during the outpatient clinical encounter? • 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

33. 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 Practices included in the analysis

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 KP HealthConnect 34

35. Stronger implementation was associated with significant performance improvement

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 Sick-care MediCaid Disease Management Chronic Condition Care Public Health

41. We always had the answers

42. …we just didn’t know they were in our own backyard.

43. Thank you for your leadership! Contact: Winston.F.Wong@kp.org