Spreading and Scaling Kaiser Permanente’s Primary Care Plus: An Interdisciplinary, Person-Centered Primary Care Model

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https://doi.org/10.7812/TPP/18-071-14

Abstracts from the Kaiser Permanente 2018 National Quality Conference

From Colorado, Southern California

Background: Kaiser Permanente (KP) is committed to developing and implementing a systematic, crossregional plan to design, test, and scale programs addressing patients with complex health and social needs. The positive impact of Primary Care Plus (PC+) in KP Colorado (KPCO) resulted in a desire to further learn about person-centered primary care team models across KP. In early 2017, KP launched a direct replication of the PC+ model in KP Southern California’s (KPSC’s) Woodland Hills Medical Center to understand the impact and scalability of PC+.
Methods: KPCO’s PC+ followed strict eligibility criteria to capture high-need, persistently high-cost members older than age 65 years (or age 18-64 years who are enrolled in Medicare). The evaluation design was a prospective matched control study assessing cost and utilization of members from a single clinic at 12 months of enrollment. KPSC Woodland Hills’ PC+ adheres to the same eligibility criteria, but the evaluation is a randomized controlled study design using an intention-to-treat approach. The evaluation will assess costs, utilization, and quality of life. All primary outcomes measures will be measured at 12 and 24 months from baseline.
Results: Most recent cohort study findings include statistically significant benefit in mean total health care costs at 12 months for PC+ members vs matched controls; cost savings in inpatient, Emergency Department, skilled nursing facility, and pharmacy expenditure buckets; and PC+ members were more likely to have been screened for depression and anxiety. In addition, the early assessment evaluation reported high satisfaction among practitioners, staff, members, and caregivers.
Discussion: As PC+ spread within KPCO and into KPSC, maintaining adherence to the patient population, core model components, and study design is critical in studying the long-term Triple Aim results of this complex care model. Documentation of PC+ protocols in an implementation guide played a critical role in the ability to spread the intervention to additional medical offices at KPCO and to a replication at Woodland Hills in KPSC. In 2017, Woodland Hills began replicating PC+, with consultative guidance from the KPCO PC+ leadership team; this allows for crossregional transfer and further study of this complex care model. Beginning in May 2018, PC+ will also be tested at the Los Angeles Medical Center in KPSC.

Abstracts from the Kaiser Permanente 2018 National Quality Conference

Quality improvement (QI) activities are essential to create a learning health care system. Publishing QI activities has great value, encourages greater rigor, and helps facilitate greater willingness to share improvement opportunities.

X Project: Getting Grounded—How Project Chamai Is Poised to Serve Emotional Wellness Needs of Kaiser Permanente Members
Trina Histon, PhD; W Scott Heisler, RN, MBA; Herbert Ozer, LCSW; Paul Castaldo, LCSW

Depression Care Management—an Evidence-Based, Collaborative Care Approach to Treating Depression in a Primary Care Setting
Alisa Aunskul, MSHCM; Daniel Hackett, MD; Karen Coleman, PhD; Mark Dreskin, MD

Moving Upstream: Three Regions’ Approaches for Addressing Social Determinants and Needs to Improve Health Outcomes
Nicole Friedman, MS; Irene Alvarez-Zamzow, MPH; Adam Sharp, MD, MS; Ranu Pandey, MHA

The Community Action Poverty Simulation: A Powerful, Interactive Experience, Moving People to Make a Difference
Anna Khachikyan

The E-SCOPE Initiative: A Strategic Approach to Identify and Accelerate Implementation of Evidence-Based Best Practices
Joel Whittaker, MPH; Joanne Schottinger, MD; Michael H Kanter, MD; Marguerite Koster, LMFT, MA

Continuing Care Quality Management: Right Care, Right Time, Right Place Applied to Skilled Nursing Facility Care
Peter Khang, MD; Jennifer Cortez; Christine Jordan; Artem Aghourian

Changing Regional Surgical Practice to Improve Quality and Efficiency of Care
Charles Meltzer, MD

Sepsis Showdown: A Unified, Interregional Approach to Sepsis Diagnosis and Treatment
Cara Steinkeler, MD; Kenneth Robinson, MD

Preventing Unrecognized Deterioration and Honoring Patients’ Goals of Care by Embedding an Automated Early-Warning System in Hospital Workflows
Brian Dummett, MD; Shirley Paulson, RN, DNP; Elizabeth Scruth, RN, PhD; Julia Green, MPH; Theresa Villorente, MSN, RN; Liesel Buchner, RN, CCRN-K, CNML; Tamar Fendel, MPH; Vivian Reyes, MD; Gabriel J Escobar, MD

Using Lean Management to Drive Improvement at East Denver Medical Office
Kristin Banks, DrPH, MPH; Tom Kazutomi, MA, NRP; Mehul Gandhi, MD, MBA; Hanah Polotsky, MD, MBOE

Spreading the News: Prevention of Hospital-Acquired Pneumonia is Possible
Cristine Lacerna, RN, MPH, CIC; David Witt, MD, FIDSA; Lawrence Block, Quality Oversight Support; Donna Patey, RN, CNS, WOCN

Same-Day Bilateral Cataract Surgery: Providing More Value to Members and to Kaiser Permanente
Robin Cisneros; Neal Shorstein, MD; Alan Moreno

The Impact of Improving Access to Primary Care
David Glass, PhD; Michael H Kanter, MD; Paul Minardi, MD

Spreading and Scaling Kaiser Permanente’s Primary Care Plus: An Interdisciplinary, Person-Centered Primary Care Model
Tracy Ellen Lippard, MD; Sara Armijo; Amy Wolf, MD; Linda Donner, MHA

Imaging to Treatment: Leveraging Technology to Redesign Care for the Pulmonary Nodule Pathway
Ashish Patel, MD; Daniel Navarro, MD; Michael Rizzo, MD; Steven Levine, MD; Todd Osinski, MD

Bringing Hospital Care into the Home: Designing for Spread of AMCAH and SY@H
Bruce Cohn, MD; David Wong, MD; Zeth Ajemian, MA

National Total Joint Replacement Initiative: A Case Study for Accelerated Systemwide Spread and Learning
Jeff Convissar, MD; Kate Koplan, MD; Ronald Navarro, MD; Violeta Rabrenovich, MHA, CHIE

Care Without Delay
Serge Teplitsky, RN; Vivian Reyes, MD; Jennifer Misajet, RN; Catherine Winarsky, MPH, BSc (Pharm)

Optimal ESRD Starts: Moving Upstream Chronic Kidney Disease to Prevent or Delay End-Stage Renal Disease with Predictive Analytics
Sophie Taylor, RN; Alvina Sundang; Leonid Pravoverov, MD; Karen Ching, MD

Committee for Improvement of Performance Through People: Strengthening Influence Over Work and Engagement in Primary Care Clinical Pharmacy
Beverly Kroner, PharmD; Alex Block, PharmD

Deprescribing: A Graduation in Medicine
Christopher C Change, PharmD, BCGP, PMP; Lynn Deguzman, PharmD, BCGP; Maisha Draves, MD, MPH

Pharmacy and Care Management Collaboration to Improve Health Outcomes through Medication Reconciliation Program Expansion
Bryan Davis, PharmD

“There’s No Place Like Home”: Creating a Safe, Individualized, Transitional Care Pathway After a Skilled Nursing Facility Stay
Yvonne Rice, PharmD; Hannah Austin, MBA; Preston Peterson, MD

Collaborative Protocols between Physicians and Pharmacy Groups to Facilitate Opioid Reduction in the Napa-Solano Service Area
Jeff Chen, PharmD; Diparshi Mukherjee, DO

Improving Performance on Medicare Stars Medication Adherence Measures through Predictive Analytics
Heather Qian, MBA; Lynn Deguzman, PharmD, BDGP; Scott Jacobs; Kevin Chiang, PharmD; Chris Chang, PharmD, BCGP, PMP

A Successful Multimodal Initiative to Increase Access to Long-Acting Reversible Contraception Among Adolescents
Sharisse Arnold-Rehring, MD, FAAP; Jennifer Seidel, MD

Patient Partners Redesign kp.org Personal Action Plans
Hyewon Jun, MD, MPH; Gordon Ching, MBA; Julia Gregory, RN, BSN

Nothing About Patients Without Patients: Strategically Partnering with Leadership for Patient-Centered Outcomes
Linda Fahey, RN, NP, MSN; Kerry Litman, MD; Susie Becken; Barbara Lewis; Diana Palma, MHA

Human-Centered Design @ KP: Building Organizational Capacity in Innovation and Patient Engagement
Loulia Kachirskaia, PhD; Jeff Hall; Jonathan Bullock

Engaging with Members to Develop a Person-Centered Transgender Care Program
Felipe Dest, MHA; Erica Metz, MD; James Kelleher, RN; Stephanie Detlefsen, MD; Erin Waters

Putting the Patient First—Shared Decision Making at Kaiser Permanente
Andrew Felcher, MD; Matt Handley, MD

Improving the Culture of Safety: Workplace Safety Unit-Based Teams Interventions that Work
Barbara Zelinski, MBA; Leslie Pole, MA; Samantha Imada, MA

Leading Inclusively—Utilizing KP’s Seven Inclusive Attributes to Build Trust and Increase Engagement and Team Productivity
Susan Terrill; Laura Long, MBA

How Our Unique Multidisciplinary Care Model Leads to Superior Outcomes for Cardiac Surgery Patients
Yong Shin, MD; Brian Timm, PA-C; William Shely, MD; Thomas Lampros, MD; David Tse, MD; Josh Andrew, PA-C; Julie Faulk, PA-C; Piotr Starosta, PA-C; Victoria Brownlow, PA-C

May The Schwartz Be With You: Fostering Ethical Care Environments through Schwartz Rounds—A Live Demonstration
Paula Goodman-Crews, LCSW; Deborah Kasman, MA, MD; Felicia Cohn, PhD

Nurse-Led Strategies to Improve In-Hospital Code Blue Survival Rates
Rebecca Campbell, RN, CCRN; Patrice Chatterton, RNC, CPHQ; Christopher Cox, RN, CEN, CCRN; Anna Sandgren, RN

Workplace Violence Prevention
Robert Durand, CPP, CHEP, HEM, CHSS; Jeff Kostos, CSP

Pain Rounds: Implementing an Interdisciplinary Team-Based Approach to Pain Management for Inpatient Rehabilitation
Brian Theodore, PhD; Ryan Doan, MD

Optimizing Specialty Palliative Care: Five Key Strategic Initiatives
Dana Benton, RN, MS, CNS; Melissa Stern, MBA

Northern California Medi-Cal Onboarding: Upstream Engagement
Sarita Mohanty, MD; Bryan K Lee, MD; Molly Drebes, MS; Irene Alvarez-Zamzow, MPH

Embrace New Culture in Postacute Care: Shaking up the Status Quo
David Wong, MD; Karen Sirski-Martin, RN, MSN, CCRN, HACP; Cora Bailey, RN, MSN, PHN, CLNC

Effective Rounding for Quality and Safety
Maggie Robbins, MPH; Lizabeth Taghavi

Pursuing Health Equity: Our Journey to Improve Diabetes Control With Our Hispanic/Latino Population at Kaiser Permanente in Indio, California
Frank Flowers, MD; Jose Fernandez, MD; Robert Blair, MPH; Patrick Calasan, BSN RN MHA

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