Supportive Care for Complex Needs—Kaiser Permanente Care Team Management Models


Tracy Ellen Lippard, MD; Stacey Moret, MOT, OTR/L;
Michelle Wong, MPH, MPP

Introduction: Responding to the needs of patients with complex needs is currently inadequate. Patients with complex needs suffer from medical comorbidities, functional limitations, and unmet social needs.
Methods: Kaiser Permanente (KP) Colorado’s Primary Care Plus (PC+) followed a strict eligibility criteria to capture high-need, high-cost members older than age 65 years (or age 18-64 years on 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. KP Northwest’s (KPNW’s) Team-Based Care (TBC) evaluation design was a retrospective matched control study that compared members 12 months pre-enrollment and 23 months postenrollment. A secondary assessment sampled members enrolled in TBC for 12 months between summer 2014 and summer 2015.
Results: In Colorado, office visit costs were 21% higher among PC+ participants compared with the control group; however this cost was more than offset by inpatient costs that were 75% lower among participants. In contrast to PC+, KPNW’s TBC did not show a significant difference in cost and utilization (ie, operating cost per patient per month, admits per 1000 patients, average length of stay, inpatient cost per patient per month, Emergency Department [ED] visits per 1000, and ED visits per member).
Discussion: Early assessment evaluations of both programs reported high satisfaction among clinicians, staff, members, and caregivers. In addition, among the initial group of PC+ program participants, 104 members had 21 important pharmacy interventions (ie, alendronate starts) within the first 6 months of enrollment compared with zero in the matched control group of 108 patients. The PC+ intervention group also saw an increase of specialty palliative care/hospice touches from 8% to 55%.
Conclusion: Initial findings from PC+ and TBC indicate that holistic, interdisciplinary focus on what matters most to high-cost, high-need members and their caregivers, with proactive outreaches and improved access to someone who knows them well, can yield benefits across the quadruple aim.


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