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”

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Healthcare’s “Middle Space”…An Innovation Mother Lode

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Healthcare’s “Middle Space”…An Innovation Mother Lode

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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

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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…

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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%

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If I only had a heart…

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Co-morbidities are Common

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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

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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.

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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

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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

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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

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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

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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?

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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

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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

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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

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KPHealthConnect

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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

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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

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If I only had courage. . .

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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

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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?

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Healthcare’s “Middle Space”…An Innovation Mother Lode

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We always had the answers

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

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Thank you for your leadership!

Contact: Winston.F.Wong@kp.org