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Kaiser Permanente Patient Center Medical Homes: Lessons Learned in Two Residencies and Applicable Elsewhere

Timothy A. Munzing M.D.

Walt Mills, M.D.

May 2008

New Medical Home

    * Objectives:
          o Describe how Kaiser Permanente is redesigning for Pt. Centered Medical Homes
          o Describe how 2 KP residencies are teaching this to faculty and residents
          o Explore how curricular areas may be used – EHR, Chronic Dz Mgmt, Secure Messaging, Advanced Access, Group Visits, etc.


ACGME Competencies

    * Patient Care
    * Medical Knowledge
    * Practice-Based Learning and  Improvement
    * Interpersonal and Communication Skills
    * Professionalism
    * Systems-Based Practice


Kaiser Permanente Orange County

    * Founded 1994
    * 18 Residents – 6/6/6
    * 100% Managed Care – 385,000 patients
    * 2 medical centers
    * Suburban Southern California
    * FMC – 50% Latino population
    * Family Physician faculty – 9 Admin & 25 Total
      (department of 140 FP’s)


Family Medicine is new to NC Residency Programs

Santa Rosa Family Medicine Residency Consortium established 2007

    * General Practice Internship Founded 1938
    * One of first Family Medicine Residencies 1968
    * 36 Residents (12-12-12)
    * 9 Core Faculty; 211 Consortium Faculty; one FPC; 3 hospitals
    * New Fellowship in Integrative Medicine 2008
    * Transitioning from Sutter (Community) Hospital to Consortium
          o Kaiser Institutional GME Sponsor
                + Kaiser pays salary, wages, benefits for 36 Residents; Faculty Development, Consortium Administration
                + Sutter Foundation employs most Core Faculty still
                + Federally Qualified Health Clinic runs Family Medicine Center
                + Memorial Hospital other major Hospital Campus
                + UCSF Affiliate
                + Consortium Board: Kaiser, Sutter, Memorial, Southwest Community Health Centers, UCSF, County Health, Residency


Patient Center Medical Home Attributes

    * Patient-centered care
    * Whole-person orientation
    * Care provided within a community context
    * Team approach
    * Elimination to barriers of access
    * Advanced information systems
    * Emphasis on quality and safety
    * Enhanced practice finance
    * Commitment to provide basket of services



Basket of Services – New Model

    * Health care provided to children and adults
    * Integration: coordinate and facilitate care
    * Disease prevention and health promotion
    * Patient education and support for self-care
    * Diagnosis and management of acute injuries and illnesses
    * Diagnosis and management of chronic diseases
    * Supportive care, including end-of-life care
    * Maternity care; hospital care
    * Primary mental health care
    * Consultation and referral services as necessary
    * Advocacy for the patient within the health care system
    * Quality improvement and practice-based research



Teaching New Model of Family Medicine 
2008 SR Family Medicine Residency Self Assessment
GPA=2.0 (C)

    * Open access scheduling (D)
    * Online appointments (F)
    * Electronic health record (D)
    * Group visits (B)
    * E-visits (F)
    * Chronic disease management (C)


    * Web-based information (B)
    * Team approach (B+)
    * Guideline software (B)
    * Outcomes analysis (D)
    * Alternative payment models (C)


FPC Current Paper Charts

    * 2008 eClinical Works EMR
    * Model Office Re-design


New Building = New Model 2010

P4 Project-Santa Rosa Program 

    * 2006 Santa Rosa FMR was in final 40 applications for P4P (Preparing Physicians to Practice Primary Care in the 21st Century)
    * 2007 Established a P4 Program Development Plan
          o Faculty Development 2007-2012 Program (Kaiser Grant)
          o Curriculum Development “Bridges to Excellence” 2008-2010
          o Model Office Planning 2007-2010
                + New Building 2010
                + Electronic Health Record FPC 
                      # eClinical Works 2008


            “Bridges to Excellence” Project:
Kaiser Family Medicine Department Offsite Asked the question “What is KP stellar at? What does it want to be known for within Residency Education? How Kaiser contribute to training the next generation of Family Physicians? 

    * Service and Access
    * Quality
    * Population Based Medicine
    * Chronic Disease Management
    * Preventive Medicine
    * Evidence Based Medicine
    * Information Technology
    * Group Visits
    * Health Education and Promotion
    * Integrated Model of Care
    * System Based Care
    * Professionalism-communication (Four Habits Model)
    * Team Based Care
    * Culturally Sensitive Care (establishing Latino Clinic Module)
    * Community Based Medicine


Bridges to Excellence Program Development 

    * Background: TransforMED, an AAFP practice redesign initiative, six-year project, is asking that Residency’s develop curriculum “Preparing the Personal Physician for Practice”, or P to the fourth power, P4. The Workgroup proposes FMS develop a P4P curriculum
    * General Principles: Will be integrated into Kaiser FMS Department with Key Faculty during R2 and/or R3 years
    * Resident seeing pts in our department
    * Curriculum designed to maximize Residents acquisition of tools to practice medicine in 21st Century New Model for care
          o Theory and applications of Pop Mgmt, Adv Access, E-Med, Panel Mgmt, Chronic Disease Mgmt, Service Excellence, QI


Consortium Faculty Development Program 2007-2012 

    * Q 6 months Workshops focused on New Model Teaching
    * New FPC Ambulatory Care Curriculum; Evaluations emphasizing the Six Competencies applied to New Model
    * New Preceptor Training (with EMR, New Innovations, and Audiovisual Precepting)
    * Effective Faculty Evaluations and Professional Development (KP $125,000 Grant)
    * New Model Family Medicine Fellowships
          o First is Integrative Medicine Fellow emphasizing “Relationship Centered Medicine”
    * Residency Solutions Program Consultation and Five Year Consortium Business Plan promoting “Residency Excellence”


Improved Quality Outcomes





Colon CA Screen





Cervical CA Screen





Breast CA Screen





HTN Control





CAD LDL < 100





DM LDL < 100






Embed the “Right Thing to Do” into Every Point of Care

Adapted from: Hyatt JD, Benton RP, Derose SF, JCOM, April 2002

Member Centered Care Management

Specialty Care

    * Reminder/Prompts
    * Diabetes Lab Panel
    * Access to Registry


Primary Care

    * Reminder/Prompts
    * Diabetes Lab Panel
    * Access to Registry


Rehabilitation Facility

Skilled Nursing Facility


    * Outreach Letters
    * Telephone Outreach
    * Flu Shot Reminders
    * Healthphone
    * Healthwise Handbook
    * Member Web site
    * Remote Monitoring



    * Automated 



    * Protocols
    * Alerts
    * Counseling




Urgent Care

    * Reminders/Prompts


Emergency Room

    * Reminder/Prompts
    * Standing Orders
    * Protocols


Call Center/ Advice Nurse

    * Scripts
    * Protocols



    * Reminders/Prompts
    * Treatment Protocols
    * Standing Orders
    * Blood Sugar Testing 
      as Vital Sign


Care/Case Management

    * Protocols


Patient Satisfaction

    * ASQ
    * MPS
    * Meteor
    * Individual Physician Satisfaction Scores 
      (Average 9.35 out of 10)


Access Measures

    * Panel Management
    * Bonding Rates (% of time PCP’s patients saw the PC)
    * Patient’s perception of access – survey


Chronic Disease Management

    * Major emphasis of the ambulatory curriculum
    * Intervention both prospective and retrospective
    * In reach and outreach


Metrics Tracked 

    * Breast Ca Screening
    * Cervical Ca Screening
    * Colon Ca Screening
    * HTN in control
    * Osteoporosis Screening
    * Peds Immunization
    * Adult Immunization
    * Asthma – IAI / BAG use
    * Smoking advice


    * Diabetes
          o HgbA1c < 7.0
          o LDL < 100
          o Retinal Screening
          o Foot Exam
          o ACE-I use
    * CAD – LDL <100
    * Chlamydia Screening


Quality Improvement

    * Ambulatory Based Quality Metrics
          o Medication Usage Evaluation
                + Non-formulary medication use
                + Antibiotic utilization
          o Patient Satisfaction Scores by individual physician
          o Performance Improvement
                + Clinical Strategic Goals
                + Chronic Disease Management
                + Family Medicine Quality Newsletter
                + Appropriate use of ambulance services


Chronic Disease Management
(Transitioning to Patient Centered Approach)

    * Smoking Cessation
    * Pneumovax and other immunizations
    * Pap
    * Mammography
    * Asthma


    * DMA1c >7
    * DM A1c testing
    * DM foot exam
    * DM retinal photos
    * Colon CA screening


    * HTN
    * CAD LDL testing
    * CAD LDL>100
    * DM LDL >100














Chronic Disease Management

Can drill to individual

physician and patient

Quality Improvement – Hospital

    * Hospital-Based Quality Metrics
          o Transfused to Cross-matched Ratio
          o Hospital Deaths
          o Hospital Readmissions within 48 hours
          o Medical Records (dictations and pharmacy orders)
          o Hospital Utilization
          o Patient Safety Goals
          o Case Reviews
          o Pharmacy and Therapeutics (Adverse drug reactions, do not use abbreviations)


Patient Safety Goals 2008

    * Improve the accuracy of patient identification.
    * Improve the effectiveness of communication among caregivers.
    * Improve the safety of using medications.
    * Reduce the risk of health care-associated infections.


Patient Safety Goals

5. Accurately and completely reconcile medications across the continuum of care.

6. Reduce the risk of patient harm resulting from falls.

7. Encourage patients’ active involvement in their own care as a patient safety strategy.

8. The organization identifies safety risks inherent in its patient population.

Questions and Dialogue