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High-Tech Resources Plus Personal Attention Creates a Comprehensive Diabetes Program

The comprehensive Diabetes Program at the Palo Alto Medical Foundation uses screenings, classes, nurse educators, wellness programs, and online medical records to provide diabetic patients with the individualized lifestyle support that they need.


Diabetes Program Emphasizes Individual Care
http://www.pamf.org/news/services/0508diabetesprogram.html

New drugs and treatments make it easier than ever for individuals with diabetes to avoid many of the serious health consequences of the disorder. However, patients still need to make lifestyle changes and work closely with their health care team to control the disease.

This is why PAMF’s Diabetes Program combines high-tech resources with personal attention to provide patients with the comprehensive tools and support they need to be their healthiest.

“As many resources as we now have for high-tech disease management, setting lifestyle goals is a process that must take place one-on-one with the patient playing an active role,” says Linda Klieman, R.N., MSN, ANP, a nurse care manager for PAMF’s Online Disease Management. “If the patient doesn’t have buy-in to the changes he or she will need to make, it will not work.”

Diabetes is an increasingly common disorder where the body loses the ability to regulate how much sugar is in the blood. According to the U.S. Centers for Disease Control and Prevention, one in three Americans will now develop diabetes in his or her lifetime.

Diabetes cannot be cured, but it can be controlled with medical treatments such as injections of the sugar-processing hormone insulin, and lifestyle changes such as eating a diet lower in sugar and fat, exercising more and losing weight.

However, making these lifestyle changes is easier said than done. For patients with type 2 diabetes, which is the most common and fastest growing form of the disorder, the diagnosis typically comes after age 40, when the diet and exercise habits that put them at risk for diabetes in the first place have become ingrained over the years, and thus are more difficult to change.

The symptoms of type 2 diabetes are often outwardly mild and may include feeling fatigued and irritable, being very thirsty, having blurred vision, and urinating more frequently. Because few people see their doctors for such symptoms, as many as a third of people with diabetes may not even know they have it. However, inside the body, diabetes can begin to damage organs and the circulatory and nervous systems long before the disease is detected. To increase the chance that diabetes is caught early, PAMF doctors typically recommend that all pregnant women and anyone who has one or more diabetes risk factors — including being overweight, having high blood pressure, being over age 45, having a close relative with diabetes or being a member of an ethnic group that has a high incidence of the disease — have their blood glucose level tested.

To keep diabetes patients committed to controlling their disease — not just for a few months or years, but for the rest of their lives — PAMF’s Diabetes Program offers a broad array of resources that can be combined in numerous ways to meet individual needs:

  • For those who feel most comfortable in group situations, PAMF offers classes on diabetes-related health topics, and a monthly support group for patients and their families.
  • Patients who prefer to research their disease on their own can visit PAMF’s Community Health Resource Centers and receive assistance from a registered nurse health educator.
  • Individuals who are having a hard time controlling and managing their diabetes may receive individual phone and in-person consultations with a PAMF diabetes educator. In addition, if depression is making it hard for patients to take charge of their lives and their disease, PAMF offers a weekly “Diabetes and Depression” drop-in support group.
  • For patients with special needs, like diabetes during pregnancy (gestational diabetes), or individual cultural concerns and risks factors, there are resources tailored just for them. These include a special Gestational Diabetes class and the PRANA (Prevention and Awareness for South Asians) Wellness Program.
  • Finally, for patients who have their disease under control and need little added support, viewing their electronic health record online via PAMFOnline, PAMF’s e-health service, can help them keep track of medications, test results and health care appointments, anywhere there is access to the Internet. One diabetes patient, for example, uses PAMFOnline to manage his disease as he travels around the country by RV for months at a time.

“In the future, even more patients may choose to take advantage of these high-tech disease management capabilities, but the human element will always be at the heart of any diabetes program,” said PAMFOnline Manager Barbara Love.

Keywords: California, care coordination, care team, chronic care, diabetes management, disease management, electronic medical record, evidence-based medicine, health information technology, health education, Palo Alto Medical Foundation, patient support, preventive care, treatment

FOR MORE INFORMATION:

Jill Antonides
Director, Communications and Public Affairs
Palo Alto Medical Foundation
795 El Camino Real
Palo Alto, CA 94301
tel. 650.691.6240
antonij1@pamf.org
www.pamf.org

Shared Medical Records Engage Patients and Manage Populations

Group Health Cooperative, a large, integrated health care system, facilitates patient-provider communication and empowers its patients to share responsibility for their health and health care by offering an array of interactive services and tools on its Web site. As part of a secure member portal, a system-wide online shared health record allows patients to access medical records online; provides secure e-mail access to physicians; and offers the ability to complete an interactive electronic health-risk assessment. The system also allows patients to easily access relevant educational information, obtain test results, and schedule appointments.


Excerpted from:

AHRQ Health Care Innovations Exchange
“Innovation Profile: Online Tools and Services Activate Plan Enrollees and Engage Them in Their Care, Enhance Efficiency, and Improve Satisfaction and Retention”
http://www.innovations.ahrq.gov/content.aspx?id=2133

Problem Addressed
The Internet offers great potential to help patients engage in their care–and pursue that care efficiently–via functions such as online medical records and e-mail communication with providers. However, few patients have access to these services.

  • E-mail communication with providers is rare, despite consumer interest: According to a recent study, only 24 percent of physicians used e-mail to communicate with patients in 2004–2005. However, a 2002 Harris Interactive poll conducted found that 90 percent of U.S. consumers with Internet access would like to be able to communicate with their providers via e-mail.
  • Access to online medical records is even rarer: One survey found that up to 96 percent of the population does not have online access to their medical records.

Description of the Innovative Activity
Group Health Cooperative enables patients to communicate easily with their providers and empowers them to participate in their health care through an online patient portal, called MyGroupHealth, that includes a comprehensive shared health record and electronic health risk assessment. The shared health record is an online medical record that includes secure e-mail access to every Group Health Cooperative care provider and to laboratory and other test results, allergy information, and visit summaries.

The portal also allows enrollees to access educational information tailored to their specific condition(s), schedule appointments, and complete an electronic health risk assessment, an interactive tool that collects important clinical information and integrates it into the electronic medical record (EMR). Group Health also recently began offering tools to enrollees to assist in deciding whether to undergo common elective surgical procedures. . . .”

Keywords: communication, electronic medical records, health risk assessment, Group Health Cooperative, health information technology, MyGroupHealth, patient portal, patient support, physician e-mail, population health, treatment, value, Washington

FOR MORE INFORMATION:

Stephen Tarnoff, MD
Associate Medical Director, Strategy & Business Development
Group Health Cooperative
320 Westlake Ave. N., Suite 100
Seattle, WA 98109-5233
tel. 206.448.5006
tarnoff.s@ghc.org
www.ghc.org

Proactive Office Visit Program Significantly Improves Quality of Care

Kaiser Permanente’s Southern California region has increased the use of preventive cancer screenings and effectively encouraged improved maintenance of cholesterol by coordinating care across all who touch patient’s lives and integrating incentives and information technology.


Excerpted from Kaiser Permanente case study:
http://xnet.kp.org/future/ahrstudy/032709proactive.html

“Kaiser Permanente’s Southern California region has increased the use of preventive cancer screenings and effectively encouraged improved maintenance of cholesterol by coordinating care across all who touch patient’s lives and integrating incentives and information technology. The proactive office encounter program fosters cooperation among providers: Clinical care teams composed of doctors, nurses, medical assistants and other staff work together to identify opportunities to engage patients and provide support and encouragement for positive action across the continuum of health care services. In addition, front-line union employees are financially rewarded through a performance sharing program when quality care goals, many affected by these types of screenings and preventative measures, are achieved.

The Challenge: Increasing Use of Preventive Care

Individuals in the U.S., regardless of insurance status, receive only about 55 percent of recommended health care, according to a 2004 RAND Corporation study. From preventive health screenings to routine monitoring and maintenance of treatable chronic health conditions, U.S. citizens under-utilize available basic care services.

Recognizing the need to improve delivery of health prevention services, Kaiser Permanente’s Southern California region created the proactive office encounter program to identify and target patients with chronic medical conditions and encourage them to be active participants in their own care. The program uses all members of the clinical care team in a coordinated and collaborative effort to engage, encourage and support patient health. The information and tools provided have helped increase preventive screenings and improve treatment adherence.”

Keywords: breast cancer screening, care teams, communication, cervical cancer screening, cholesterol control, chronic care, collaborative care, colon cancer screening, disease management, electronic medical record, evidence-based medicine, health information technology, integrated care, Kaiser Permanente, kp healthconnect, preventive care, safety, Southern California, treatment, value

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

 

HealthPartners Creates the Infrastructure to Deliver Optimal Care

Operating on the assumption that physicians, hospitals, and other providers truly want to deliver the best care for their patients, HealthPartners is creating the infrastructure to make optimal care the easiest care to deliver. For example, two years ago, HealthPartners introduced a radiology management program that reduced the number of unnecessary high-tech images by 7,000 in the first full year of operation–and cut costs by $6.6 million over what would have been spent without the program.


Excerpted from:

Health Finance Management Association/Leadership Case Studies: Designing Incentives that Reward High-Quality Cost-Effective Care
http://hfma.org/leadership/DesigningIncentives.html

Radiology Management
Two years ago, HealthPartners introduced a radiology management program that reduced the number of unnecessary high-tech images by 7,000 in the first full year of operation–and cut costs by $6.6 million over what would have been spent without the program.

“Under the program, physicians who use a decision-support tool in their EHRs–which informs them of the appropriate test for a given medical situation–do not have to seek approval before ordering scans. Physicians who do not use EHRs can get decision support in other ways (for example, from the referring radiologist or an online decision-support database). 70 percent of HealthPartners members are now treated by physicians with EHR-based decision support.

“Even though radiologists saw the growth of their businesses slow as referring physicians opted for fewer MRIs and PET scans, they supported the initiative because it is part of a communitywide, and highly publicized, effort to reduce unnecessary diagnostic imaging in Minnesota.

“Important support also came from HealthPartners’ Medical Group physicians. ‘Our medical group knew that we and other health plans were going to be doing something to better manage radiology, and asked, “Can we build a clinical capability to address this?”‘ says Dr. Pat Courneya, associate medical director. The medical group physicians developed the decision-support content to be used in their own medical record system–and gave the tool to other physicians in the state who use the same medical record system. . . .”

Keywords: decision support, diagnostic imaging, EHR, EMR, electronic medical record, HealthPartners Medical Group, health information technology, Minnesota, MRI, medical record system, optimal care, PET scans, radiology management, value

FOR MORE INFORMATION:

Amy von Walter
Director, Corporate Communications
HealthPartners
8170 33rd Avenue South
Bloomington, MN 55425
tel. 952.883.5274
amy.e.vonwalter@healthpartners.com
www.healthpartners.com

Patients with Chronic Diseases Benefit from Support Targeted to the Level of Care They Need

Patients who have chronic diseases or who are at risk of developing one require different levels of support and care. Kaiser Permanente’s Northern California region developed a strategy to improve the care and outcomes for these patients by dividing their care into three well-defined levels of specialty care. Kaiser Permanente’s Colorado region later adopted the strategy to include a telephonic cardiac medication management service.


Excerpt from Commonwealth Fund case study:

Kaiser Permanente: Bridging the Quality Divide with Integrated Practice, Group Accountability, and Health Information Technology

http://www.commonwealthfund.org/Content/Publications/Case-Studies/2009/Jun/Kaiser-Permanente.aspx

“The Northern California region uses a population and patient-panel management strategy to improve care and outcomes for patients who have–or who are at risk for developing–chronic diseases. This approach is built on the philosophy that a strong primary care system offers the most efficient way to interact with most patients most of the time, while recognizing that some patients need additional support and specialty care to achieve the best possible outcomes. Patients are stratified into three levels of care:

  1. Primary care with self-care support for the 65 percent to 80 percent of patients whose conditions are generally responsive to lifestyle changes and medications.
  2. Assistive care management to address adherence problems, complex medication regimens, and comorbidities for the 20 percent to 30 percent of patients whose diseases are not under control through care at level one.
  3. Intensive case management and specialty care for the 1 percent to 5 percent of patients with advanced disease and complex comorbidities or frailty.

Level one emphasizes a proactive team approach that conserves physician time for face-to-face encounters by enhancing the contributions of ancillary staff (medical assistants and also nurses and pharmacists in some locations) to conducting outreach to patients between visits. . .

At level two, care managers (specially trained nurses, clinical social workers, or pharmacists) support the primary care team to help patients gain control of a chronic condition. . . .

An example of intensive case management (level three) is a cardiac rehabilitation program called Multifit for patients with advanced heart disease, such as those recovering from a heart attack or heart surgery. Nurse case managers provide telephonic education and support for up to six months to help patients make lifestyle changes and reduce their risk of future cardiac events. Aided by the EHR and a patient registry, the Colorado region enhanced the program by adding a telephonic cardiac medication management service provided by clinical pharmacy specialists, with ongoing follow-up until patients achieve treatment goals and can be transferred to primary care for maintenance. Results for patients participating in the Colorado program included the following:

  • Cholesterol screening increased from 55 percent to 97 percent of patients, while cholesterol control has almost tripled from 26 percent to 73 percent of patients. The Colorado plan ranked first among health plans nationally in 2007 on a measure of cholesterol screening for patients with cardiovascular conditions.
  • Relative risk of death declined by 89 percent among those enrolled in the program within 90 days of a cardiac event, and by 76 percent for those with any contact with the program. An estimated 260 major cardiac events and 135 deaths have been avoided per year because of these improvements.”

Keywords: assistive care management, care coordination, care teams, chronic care, chronic disease management, communication, specialty care, case management, electronic medical record, evidence-based medicine, health information technology, Kaiser Permanente, kp healthconnect, clinical collaboration, integrated care, Northern California, patient support, population health, preventive care, treatment, value

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

HealthPartners: Closing the Gap in Health Care Disparities (Breast Cancer)

HealthPartners has made significant progress toward reducing the disparity in breast cancer screening rates between white women and women of color. In 2007, the screening disparity between white women and women of color was nearly 13 percent. Since then, the disparity has closed to an average under 5 percent and, at several HealthPartners clinics, the rates are nearly identical or better in patients of color.


More than ten years ago, HealthPartners began groundbreaking work to close a gap in health care and ensure that care and service is of equally high quality for all populations, regardless of a patient’s race or ethnicity, preferred language, private insurance or public program. To identify and address these disparities, HealthPartners leaders established the Cross Cultural Care and Service Task Force in 2001, and, in 2003, the health system developed a plan to collect self-reported patient demographic data to assist us in creating strategies and tactics to improve care and service for our patients.

Reduction in breast cancer screening disparities for women of color

HealthPartners has made significant progress toward reducing the disparity in breast cancer screening rates between white women and women of color. In 2007, the screening disparity between white women and women of color was nearly 13 percent. Since then, the disparity has closed to an average under 5 percent and, at several HealthPartners clinics, the rates are nearly identical or better in patients of color.

To achieve this, HealthPartners developed customized interventions addressing barriers affecting minority populations to better serve patients. For some women, the extra encouragement from the doctor or care team during a clinic visit made obtaining the screening more likely. HealthPartners responded with a same-day mammography program in which patients overdue for a mammogram are offered the service when at the clinic for some other reason. Other interventions include transportation assistance, telephone outreach and special scripting for providers.

mammo

FOR MORE INFORMATION:

Amy von Walter
Director, Corporate Communications
HealthPartners
8170 33rd Avenue South
Bloomington, MN 55425
tel. 952.883.5274
amy.e.vonwalter@healthpartners.com
www.healthpartners.com

HealthPartners’ ‘Care Model Process’ Creates a Patient-Centered Medical Home

HealthPartners Medical Group used its “care model process” to create a patient-centered medical home by developing primary care workflows that provide a consistent clinical experience for patients and their care teams. Standardized processes and clearly defined roles for staff enable the care teams to create a “continuous healing relationship” with patients.


Excerpted from:

Commonwealth Fund’s Case Study: Organized Health Care Delivery Systems HealthPartners: Consumer-Focused Mission and Collaborative Approach Support Ambitious Performance Improvement Agenda By Douglas McCarthy, Kimberly Mueller, and Ingrid Tillmann, Issues Research, Inc.

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Jun/1250_McCarthy_HealthPartners_case_study_61_for%20PF.pdf

“HealthPartners clinics have adopted a ‘care model process’ that defines a standard set of workflows for delivering evidence-based care. The process establishes consistent practices for care teams which provide a consistent clini­cal experience for patients.Clinic staff members are organized into ‘prepared practice teams’ composed of a physician, a rooming nurse, a receptionist and others such as a pharmacist or dietitian, when needed, to meet patient needs. The goal is to create a ‘continuous healing relationship’ between the care team and the patient by mak­ing the best use of collective team skills, enhancing communication, and ensuring that care is well-coor­dinated and responsive to patient needs.

These teams typically huddle each morning to review their schedule and objectives and plan for the day. Teams plan for patient interactions in defined cycles which include, scheduling, pre-visit, check-in, visit, and post-visit. Defining the elements of the interaction with patients allows the care team to anticipate patient needs, remind patients of health issues, and provide follow-up after the visit.

For example, pre-visit plan­ning may include identifying preventive care services that will need to be provided at the visit and contacting the patient to schedule lab tests before the visit so that results are available for review during the visit. At the patient visit, the team uses the EHR to address the patient’s health maintenance or chronic care needs, prescription refills, and schedule future appoint­ments. Patients receive an “after-visit summary” to promote better adherence to treatment and to receive outstanding lab results by their preferred method of notification (letter, phone, or online).

The care model process enabled HealthPartners Medical Group to become one of the first large multi-specialty group practices in the nation to be recognized as a Patient-Centered Medical Home by the National Committee for Quality Assurance Physician Practice Connections-Patient-Centered Medical HomeTM

Keywords: access, after-visit summary, care coordination, care model process, care team, communication, EHR, electronic medical records, evidence-based medicine, health information technology, HealthPartners Medical Group, medical home, Minnesota, NCQA, patient-centered medical home, patient support, preventive care, team huddles

FOR MORE INFORMATION:

Amy von Walter
Director, Corporate Communications
HealthPartners
8170 33rd AvenueSouth
Bloomington, MN 55425
tel. 952.883.5274
amy.e.vonwalter@healthpartners.com
www.healthpartners.com

Improved Care Transitions for Heart Failure Patients Strive to Reduce Hospital Readmissions at HealthPartners

Through the use of health information technology and hospital-based care managers, HealthPartners’ discharged heart failure patients are successfully transitioned back home. Then the patient’s pri­mary care physician co-manages the patient with a cardiac specialist in the heart failure clinic, using the electronic medical record to facilitate communication and patient reminders.


Excerpted from:

From Commonwealth Fund’s Case Study: Organized Health Care Delivery Systems HealthPartners: Consumer-Focused Mission and Collaborative Approach Support Ambitious Performance Improvement Agenda By Douglas McCarthy, Kimberly Mueller, and Ingrid Tillmann, Issues Research, Inc.

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Jun/1250_McCarthy_HealthPartners_case_study_61_for%20PF.pdf

Improving care transitions. The HealthPartners Medical Group and Regions Hospital are working together to improve care transitions for patients with heart failure. For example, primary care physicians receive an electronic alert when one of their heart failure patients is admitted to Regions hospital.

When the patient is discharged, the hospital’s care managers notify the medical group’s heart failure clinic and telephone the patient at home to ensure that he or she has a follow-up appointment and is taking the proper medications. The patient’s pri­mary care physician and a cardiac specialist in the heart failure clinic then co-manage the patient with a jointly agreed-upon follow-up schedule, using the EHR to facilitate communication and patient reminders.

“To promote improved care transitions across its network, HealthPartners health plan recently began reporting on hospital readmissions for heart failure patients for each of its cardiology care groups. As part of its per­formance incentive program for contracted providers in its network, the plan has set a goal of reducing readmissions within 30 and 90 days of an initial hospi­talization to 5 percent and 15 percent of these patients, respectively, from current plan wide rates of 7.9 percent and 17.3 percent during 2005–2007. . . .”

Keywords: care coordination, care team, care managers, communication, health information technology, heart failure, HealthPartners Medical Group, hospital readmissions, Minnesota, patient support, safety, treatment, value

FOR MORE INFORMATION:

Amy von Walter
Director, Corporate Communications
HealthPartners
8170 33rd Avenue South
Bloomington, MN 55425
tel. 952.883.5274
amy.e.vonwalter@healthpartners.com
www.healthpartners.com

HealthPartners Patients Have Online Access to Care

HealthPartners Medical Group offers Online Patient Services to its patients, a feature that is part of its electronic medical record. Online Patient Services are a set of secure, web-based services—that includes online test results, refills, access to medication lists, and appointment scheduling—that allow patients to interact with their clinic, provider and medical records from any computer.

In May 2005, HealthPartners Clinics implemented Online Patient Services as part of its electronic medical record. Online Patient Services are a set of secure, web-based services that allow patients to interact with their clinic, provider and medical records from a computer. Services include:

  • Online test results (90 percent of test results are available within 24 hours)
  • Access to medication list
  • Refill prescriptions
  • View and print immunization records
  • Schedule an appointment
  • Pay a bill
  • Consult with their care team
  • Have an e-visit with a provider

Online Patient Services are available 24 hours a day, 7 days a week Online Patient Services give patients a better way to solve problems by giving them more control over their care. For example, patients with chronic illnesses such as diabetes can get test results more quickly, communicate with their care team or provider, and refill prescriptions without coming into the clinic. Overall, nearly 30 percent of active patients in HealthPartners Clinics are enrolled in Online Patient Services

KEYWORDS:access, care team, communication, health information technology, e-Visits, HealthPartners Medical Group, Minnesota, Online Patient Services, same-day test results, patient support, safety, treatment

FOR MORE INFORMATION:

Amy von Walter
Director, Corporate Communications
HealthPartners
8170 33rd Avenue South
Bloomington, MN 55425
tel. 952.883.5274
amy.e.vonwalter@healthpartners.com
www.healthpartners.com