ACHP Medical Directors Meeting September 29, 2005

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ACHP Medical Directors MeetingSeptember 29,
2005

• Leslee J. Budge, MBA

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Outline

• Where we started
• How we use registries
• Moving to from disease silos to multiple
  conditions
• Moving from disease management to whole person
  management
• Supporting primary care physician panel
  management
• Using the health care team in the visit continuum

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Where we started
Population Management Disease Management

• Developed electronic registries that identified
  members with a specific disease, e.g., diabetes
• Segmented patients with that disease based on how
  well they were doing, e.g., HbA1c levels
• Supported care of about 5 to 10 of population
  at any one point in time with care management
  programs
• Used structured queries to identify and manage
  gaps in care for those not in a care management
  program

Issue patients with multiple conditions may see
multiple care managers
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Managing the Whole Patient

• Managing patients needs in diseases silos can
  fragment care

Many patients have multiple health care needs.
.and they want to be treated as a whole person
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Risk factors tend to cluster.
It started with cardiovascular disease
90 of member with diabetes have either
hypertension, dyslipidemia or both
Percent of KP membership, age 20 and above with
condition
Selby J, et al. Circulation 2002 106
(Supplement)(19)724
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Effective treatment is very similar for
cardiovascular diseases
ACE-I angiotensin II-converting enzyme
inhibitor BB beta-adrenergic receptor blocker,
APA anti-platelet agents
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KP is in process of implementing a comprehensive
electronic health record .
The electronic health record (EHR) is designed
for the medical office visit by supporting

• Access to past medical history by all clinicians
• Access to pending orders and results
• Electronic capture of vital signs and progress
  notes
• Problem list management

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The EHR can do some population-based care
functions .
Member Health Profiles
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Personalizing Population Care Management

• A whole member and whole population approach
• Personalized health profiles and collaborative
  action plans
• Care location/access based on member preferences
• Proactive identification of risk and care gaps
• Active promotion of healthy behaviors and
  self-care
• Tailored programs and support to fit specific
  populations, purchases, etc.
• Clinical outcome and performance reporting
• Purchaser value reports

Traditional models of Population Care
Management have been challenged to consistently
include the management of concomitant conditions
and to factor in prevention. Kaiser has a
unique opportunity to re-define its approach -
Personalized Population Care Management builds on
our integrated health care delivery system.
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Capabilities Needed to Support Personalized
Population Care Management

• Identification
• Identify health care needs and presence of
  chronic conditions
• Stratification
• Stratify risk and identify gaps in care
• Member Health Profiles
• Build a profile of members health care needs
• Collaborative Action Plan
• Agreement between the member and clinician on
  specific health care goals
• Population Management
• The ability to sorted members by chronic illness,
  physician panel, care manager, region, purchaser,
  etc.
• Member Tracking
• Track members though an episode or long-term to
  ensure timely follow-up and interventions

• Inreach
• Alerts or reminders triggered at any
  point-of-service
• Outreach
• Multi-channel outreach to one member or to many
  members
• Member Self-care
• Support members to understand and manage their
  health
• Incentive Management
• Reward members, purchasers, and health care teams
  for achieving healthy behavior goals
• Research
• Support studies to identify effective and
  efficient processes and services including
  refinement of risk modeling
• Reporting
• Generate reports to meet business and quality
  needs

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Leveraging technology and data.
PCMCapabilities
Enterprise Data Warehouse (EDW)
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Fundamental Information Model
Imagine a huge spreadsheet where we could
organize all of patients data for multiple
health care needs
.the columns define specific attributes, e.g.,
inclusion in a chronic disease population
The row is the view of the patients health care
needsthe Patient Health Profile
The fundamental information model can be
simplified to a matrix of patients, their
characteristics/attributes, and conditions
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Building Patient Health Profile
Build Patient Health Profile
Identify Opportunities Stratify Risk
Identify Patient HealthAttributes
Algorithms identify chronic conditions and
prevention needs
Evidence-based guidelines and predictive
modeling identify care gaps and high-risk members
Predictive modeling gap analysis
EDW
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Patient Engagement
Build Patient Health Profile
EDW
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Collaborative Goals Inform System Generated
Actions
Patient - clinician Collaborative Goal Setting
Collaborative action plan
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Actions effect outcomes and provide feedback loop
to improve processes
Patient Tracking
IncentiveManagement
Research
FeedbackLoop
Improve processes algorithms
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In summary.

• As we mature in our work with population care
  management we are understanding the importance of
  considering the needs of the whole member when
  providing care
• Focusing on the whole member will enable us to
  move upstream to prevent or delay future
  high-risk disease
• We are drawing on our current best knowledge and
  efforts
• To accomplish our goals we are building in small
  incremental steps, leveraging the knowledge
  gained from the previous step
• We believe building a system that is flexible and
  sharable will support the rapid diffusion of
  innovation and successful practices because
  technology will not be the barrier