1. Transforming Care in an
Integrated Health System
Benjamin K. Chu, MD, MPH
President
Kaiser Permanente Health Plan/Hospitals
Southern California Region

2. Kaiser Permanente: The oldest group model
health maintenance organization, serving 8.6
million people in 8 regions across the country
Kaiser Permanente
Kaiser Permanente’s capitated payment model
Programwide
places as much emphasis on keeping people health
• 8.6 Million Members
as it does on caring for members when they are ill.
• 32 Hospitals
• 420 Medical Office Buildings
• 14,000 Physicians
• 156,853 Employees
• $40 Billion Annual Revenue
• 600 – 700 Residents
and Fellows
• $4 Billion Health Information
Technology Investment
• 60 Years of Providing Care
• Focus on prevention of
illness and disease
2

3. 3

4. Kaiser Permanente Southern
California: Who We Are
 3.28 Million Members
 13 Hospitals
 More than 120 Medical Office
Buildings
 55,000 Employees
 6,500 Physicians
 280,000 Hospital Discharges
 34,400 Babies Delivered Annually
 17.7 Million Outpatient Visits
 22.7 Million Prescriptions Filled
 305,800 Annual Home Health Visits
 $14 Billion Annual Revenue
 Full implementation of electronic
medical record in all hospitals and
medical office buildings
4

5. A Care Model Systems Approach
Leads to Improved Outcomes
Community
Health System
Resources Health Care Organization Information
and Policies Systems
Self- Support
Management Delivery Decision
Support System Support Tools
Design
Informed,
Productive Prepared,
Interactions Proactive
Activated Patient
Practice Team
Improved Outcomes
 Source: Adapted from the Chronic Care Model,
 Ed Wagner, MD, www.improvingchroniccare.org
5

6. Kaiser Permanente’s Integrated
System Connects Health Plan and
Health Care Services
• Kaiser Permanente has
integrated finance and care
HEALTH PLAN delivery services
MEMBERS • This creates the ability to
allocate resources where
needed to achieve the best
health outcomes for the patient
• Kaiser Permanente’s capitated
payment model places as
KAISER much emphasis on keeping
FOUNDATION people health as it does on
HEALTH PLAN caring for members when they
are ill.
KAISER Southern California
FOUNDATION PERMANENTE
HOSPITALS MEDICAL GROUP
6

7. Kaiser Permanente Is Transforming from a
Traditional “Sickness Model” to Proactive Care
That Helps Prevent Debilitating Illness
What is required is a new
patient-centric care model,
which is characterized by:
 Proactive Care Processes
 Care Delivered by a Health Care
Team
 Care Integrated across Time, Place,
and Conditions
 Care Delivered through Group
Appointments, Nurse Clinics,
Telephone, Internet, E-mail, Remote
Care Technology
 Self-Management Support that Is
Integral to the Delivery System
In today’s complex health care world, in which chronic illness is a larger burden
than ever before, a single physician cannot fulfill all the functions necessary to
optimize health outcomes for patients in a series of short interactions.
7

8. The U.S. Health Care System Overall Is Terribly
Fragmented and Patient Care Is Not Coordinated
Call Center
Primary Care Advice Center
Office Skilled Nursing
Laboratory Facility
Specialty Care
Office Hospital
Home (Self-Care)
Health
Plans Urgent Care
Pharmacy
Emergency Dept. Media/Web
DME Rehabilitation Hospice
Radiology
8

9. Information Systems Allow Kaiser Permanente
to Embed the “Right Thing to Do” into Each
Point of Care
Information Systems Support Care
Across the Integrated Continuum of
Care and Contribute to a Better
Understanding of Each Patient’s
Health Needs
Primary Care
• Reminder/Prompts Call Center/ Hospital
• Treatment Protocols
• 24/7 availability of clinical Advice Nurse • Standing Orders
information • Scripts • Patient Safety
• Access to Registry • Protocols Imperative
• Decision support tools
• Highly Reliable Care
Specialty Care
• Reminder/Prompts Emergency Room
• 24/7 availability of clinical • Standing Orders
information • Protocols
• Access to Registry
Member-
• Decision support tools Centered Care Urgent Care
• Reminders/Prompts
Rehabilitation Management
Facility Care/Case Management
• Protocols
Skilled Nursing
Facility Health
Home Pharmacy
• Protocols
Education
• Outreach Letters
• Alerts
• Telephone Outreach Laboratory
• Counseling
• Flu Shot Reminders • Automated
• Healthphone Standing
• Healthwise Handbook Orders
• Member Web site
• Remote Monitoring 9
Adapted from: Hyatt JD, Benton RP, Derose SF, JCOM, April 2002

10. Kaiser Permanente’s Care Management
Support Provides Better Patient Management
Using Evidence-Based Medicine
 Patient Registry and Concurrent Tracking System
• Identifies all members in the population
• Risk stratifies population for targeting interventions and resources
• Tracks and monitors each patient for key indicators (lab, pharmacy,
encounters, clinical indicators, etc.)
• Easy Access (Web-based)
 Care Management Systems
• Flags/Alerts
• Supports Telephone management and documentation
 Supports Automated Clinical Decision Support and Practice Tools
• In-reach/Outreach
 Health Education and Self-Care Support
10

11. Kaiser Permanente Clinical Information
Systems Provide Better Patient Management
Using Evidence-Based Medicine
Registries
Labs
Risk stratification of
population
Hospital
Identify subgroups
Pharmacy needing specific care
Patient management
Outpatient tools
Appointments
Clinical Targeted panel lists
Information Prompts, reminders for
Outpatient
Encounter Systems clinicians
Letters and automated
Membership telephone outreach to
members
Emergency Monitoring and process
Department improvement measures
and reports
Immunizations Targeted health
education and self-care
support 11

12. Kaiser Permanente’s Registry for Chronic
Diseases and Panel Management Provides
Insight Across Disease Spectrums
Eight Major Clinical Registries:
 Asthma
 Heart Failure
 Diabetes
 Coronary Artery Disease
 Chronic Kidney Disease
 Cardiovascular
 Hypertension
 Panel Management
12

13. Kaiser Permanente’s Registry for Chronic
Diseases and Panel Management Provides
Insight For Each Chronic Disease
Each member of the care team can access registry and panel
management tools and play a role in addressing care gaps
13

14. Kaiser Permanente’s Registry for Chronic
Diseases and Panel Management Can Be
Used for Physician Panel Management
14

15. Kaiser Permanente Members Actively
Participate in Care Through kp.org
Member contacts with the health system increase through new modalities
• More than 2.4 million Kaiser Permanente members have access to secure health information
management features
• 160,000 access kp.org daily
• More than 10 million test results viewed in 2007
• More than 3.6 million secure e-mails sent to physicians in 2007
• 20,000 secure e-mails daily
KP HealthConnect
www.kp.org Make/Change Appointments Care Delivery Core
Member Web Portal
Send messages to doctor
Outpatient Inpatient
Scheduling Scheduling
Check lab results
Registration
Access health Information Registration
Clinicals
Access medical record
Clinicals Billing
Refill prescriptions Pharmac
On-line patient education, self-
Billing y
care modules and support provide
access to information 24/7. Emergency
Make payments Department 15

16. Electronic Medical Records Make Tracking Easy
But Achieving Better Outcomes for Patients
Requires Using This Information to Drive Change
 Kaiser Permanente needed a way to use the information in the
electronic medical record to impact the patient’s total health.
 Every patient encounter in primary care and in specialty care
creates an opportunity to provide total care.
 Staff are charged with overseeing all aspects of patient care and
determining what vital tests or screenings are missing.
 Appointments can be made on the spot or referrals generated
so gaps can be readily addressed.
 This leads to proactive care instead of reactive care after
someone presents with critical signs and symptoms.
 Kaiser Permanente’s experience shows that patients who have
the largest “gaps” in recommended care do not routinely visit
their primary care physicians. Specialty clinics must play a role
to achieve optimal results
• Fewer than 40% of patients needing a mammogram or testing for
diabetes HbA1c visited their primary care physician
16

17. Proactive Encounters Have Revolutionized
How Kaiser Permanente Provides Total Health
• Not all patients see their primary care physician.
• Every office encounter has been redesigned to optimize each patient contact.
• Areas of need are identified and acted on.
• All staff have responsibility for patient’s total health.
Pre Encounter Office Encounter Post Encounter
Proactive Office Encounter Management Immediate
Identification • Vital sign collection / • After visit summary,
• Identify missing documentation after care
labs, screening • Identify and flag alerts for provider instructions, follow-
procedures, access up appointments,
management, kp.org • Room and prepare patient for Health Ed materials,
status, etc. necessary exams how to access info
• Provide member • Pre-encounter follow-up on kp.org
instructions prior to Future
visit Back Office Support
• Follow-up contact
• Contact member and • Phone calls and appointments
document encounter • Letters per provider
in KP • E-mail
HealthConnect™ • Inbox Management
17

18. The Ability to Use, Not Just Store, Information
Electronically Results in Better Outcomes
Examples Include:
 Proper use of surgical antibiotics results in fewer surgical site
infections.
 Higher screening rates result in more cancer detection at earlier
stages
 Better blood pressure control results in fewer heart attacks and
hospitalizations for related diseases.
 Better osteoporosis management results in fewer hip fractures
among the elderly population.
18

19. Proactive Office Encounter:
Tools for Staff and Physicians to Fill Care Gaps
Special tools and systems have been designed so
each member of the care team can understand
responsibilities and track results.
• Panel Management
• Pre-Encounter, Encounter Checklists
• Proactive Care Gap Checklist
• Proactive Encounter Performance Tool
• Proactive Encounter SmartSets (KPHC)
• Utilization Reports
19

20. Proactive Care Gap Checklist
Gaps in the patients care are identified through the use of flags.
If there is a “Y”, an action is needed.
Member
Information
20

21. Outcomes: Breast Cancer Screening
Rate (ages 52–69) – #1 in the U.S.
90%
88%
86%
84%
National 90th
82% percentile
80%
78%
YE 2004 YE 2005 YE 2006 YE 2007 through 10/08
 Kaiser Permanente Southern California is #1 HMO in the country for
breast cancer screening because of ability to see who in the defined
population has not had a mammogram and schedule an appointment
(often the same day) no matter why the patient was being seen
originally.
 565 lives saved per decade
 4,349 Stage 4 cases prevented per decade
21

22. Outcomes: Colorectal Cancer
Screening
70%
65%
60%
27% Increase National 90th
55% in 4 Years percentile
50%
45%
40%
35%
YE 2004 YE 2005 YE 2006 YE 2007 through 10/08
 Ability to view medical record electronically allow staff to
see who in defined population needs an appointment for
screening.
 3,838 lives saved per decade
22

23. Outcomes: Controlling High Blood
Pressure (ages 18-85)
85%
80% 35.6% Increase
in 4 years
75%
70%
65%
60% National 90th
percentile
55%
50%
45%
40%
YE 2003 YE 2004 YE 2005 YE 2006 YE 2007 through
10/08
 Compliance with regular testing and medication are
easily captured and reviewed.
 4,890 lives saved per decade
23

24. Outcomes: Osteoporosis Management
65%
60%
55%
50%
45%
40% National 90th
35% percentile
30%
25%
YE 2005 YE 2006 YE 2007 through 10/08
 Proactive measures can reduce hip fracture rates by an average of
37.2 percent—and as much as 50 percent—among those at risk.
 National 90th Percentile for Medicare is 30%.
24

25. Outcomes: Decreased Hip Fractures by Almost
40% Due to Proactive Measures
37% total reduction in
hip fractures in older
women
Hip fractures in older
women lead to many
complications including:
• Lack of mobility
• Inability to provide self-
care
• Expensive nursing home
care
• Death
25

26. Selected Hospital Outcomes in Kaiser
Permanente
Kaiser Permanente Southern California has made dramatic gains in
important hospital measures in less than two years.
100%
95% Heart Failure Bundle
90% SCIP Composite
85%
80%
75%
70%
65%
60%
55%
50%
3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08
26

27. Better Hospital Outcomes in Kaiser
Permanente
Southern California
NNSI National BSI
4.0
Kaiser Permanente Rate
3.5
Southern California 3.0
consistently performs better
2.5 KP Southern
than most in important California BSI
2.0
hospital infection-control Rate/1000 Line Days
1.5
measures: Bloodstream
1.0
Infections and Hospital-
0.5
Acquired Pressure Ulcers.
0.0
07Q3 07Q4 08Q1 08Q2 08Q3
0.10
California HAPU
0.08 Rate
0.06
0.04
0.02 KP Southern
California HAPU Rate
0.00
3Q2007 4Q2007 1Q2008 2Q2008 3Q2008 27

28. Hospital Outcomes in Kaiser Permanente
Southern California
Kaiser Permanente Southern California consistently performs better
than the Medicare average for hospital standardized mortality rate.
80% KP Southern California
US Medicare Overall
75%
70%
65%
60%
55%
50%
3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08
* 3Q2008 Medicare hospital mortality not available
28

29. Kaiser Permanente Has Higher Cancer
Survival and Lives Saved Annually Compared
to National Data
KP 5-yr SEER 5-yr Lives
survival survival* saved/yr
Breast 92.3% 88.6% 107
Colon 72.9% 64% 132
Melanoma 97.9% 91% 76
* SEER = Surveillance Epidemiology and End
Results, part of the National Cancer Institute.
These data are for five-years survival rates.
29

30. Kaiser Permanente Addresses the Larger
Healthcare Needs of the Community
 Focus on primary care and
prevention, and addressing chronic
disease requires looking at larger
communitywide issues
 Behavioral factors are as important
as specific treatments: better diet,
reducing smoking, addressing the
epidemic of obesity, greater physical
activity
 Community education for adults and
children in recognizing bad health
habits and taking action to create a
better health outlook
30

31. Healthy Eating Active Living Program Helps
Make Healthy Choices Easy
1. Incorporate health into local planning
decisions
2. Increase access to parks and green spaces
3. Improve public access and safety in
recreation areas
4. Develop collaborations with schools
5. Establish safe routes to school
6. Promote menu labeling and making nutrition
information available to consumers
7. Increase availability of healthy foods, including
fruits and vegetables
8. Promote healthy eating in public facilities
9. Publicly recognize civic involvement and
leadership
10. Healthy choices start with you
31

32. HEAL and Operation Splash in
Southern California
Healthy Eating, Active Living
Partnership with The California
Endowment (Healthy Eating, Active
Communities)
HEAL grants are focused on policy and
environmental change
Operation Splash
Subsidized swim lessons, extended pool
season, supplies
healthy eating active living 32

33. The Amazing Food Detective:
Working on better nutrition to help
stem the rise of childhood obesity
Professional theatre troupe
performances and workshops
for 4th graders and parents
• 227 performances
• 571 workshops
• 57K kids and parents
Now a computer game:
www.kp.org/
amazingfooddetective
33

34. Farmer’s Markets at Medical Centers
Working With Local Vendors
7 farmer’s markets at medical
centers and Kaiser Permanente
Watts Learning Center provide
access to health foods for
communities that do not often have
easy access to fresh fruits and
vegetables and health snacking
alternatives.
Farmer’s Markets include:
Fresh produce
Cooking demonstrations
Wellness literature
34

35. Kaiser Permanente Works with the Trust
for Public Land to Encourage More Active
Lifestyles
Creates open space in park-poor neighborhoods and installs Fitness Zones.
 In Southern California, Kaiser Permanente has a three-year partnership with
the Trust for Public Land. Through a $750,000 grant, the Trust is assisting
underserved, park-poor communities with planning, land acquisition, and
grant development.
 The grant also funds planning and development of fitness zones – exercise
equipment that people of all ages can use. Five fitness zones have been
installed in five Los Angeles County parks in low-income neighborhoods
with high rates of obesity.
35

36. This old rail road right-of-way was
along the southeast corridor of Los
Angeles County.
36

37. Here’s the same site and what it
looks like today thanks to the Trust
for Public Land.
37

38. These “abuelitas” or grandmothers are working out in
Belvedere Park in East Los Angeles. The Trust for Public
Land developed the Fitness Zone model and works on
matching grants to install the equipment in low-income
neighborhoods.
38

39. Kaiser Permanente launched an
advertising campaign – called
“Thrive” – which emphasizes a
health message for the community
39