ello Health Information Technology Archives | Page 4 of 4 | CAPP
Share your opinion about American healthcare
Take our poll

Kaiser Permanente Colorado Improves Follow-up Care for Discharged Patients

A telephonic care coordination program at Kaiser Permanente Colorado has improved follow-up care for patients discharged from a hospital or skilled nursing facility or who are at risk of hospitalization due to multiple chronic conditions. Care coordinators contact patients within 24 hours of discharge to assess needed services and to make referrals to community resources they may need, which has been documented in their electronic medical record.


Excerpted 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 Colorado region offers a telephonic care coordination program to improve follow-up care for patients discharged from a hospital or skilled nursing facility. The program also services patients who frequently visit the emergency department (ED) or are at risk of hospitalization because of multiple chronic conditions.

Care coordinators (specially trained nurses or social workers) contact discharged patients within 24 hours to assess needs and stratify them to receive short- or longer-term services that may include verifying medications, developing self-care skills, coordinating services, and making referrals to community resources. Information on each patient contact is documented in the EHR for communication to the care team.

The plan credited the program with annual cost savings of $4 million from decreased readmissions (2.4% of intervention patients vs. 14% of usual-care patients at 12 months) and ED visits (7% vs. 16%, respectively). Satisfaction with the program exceeds 90 percent of physicians and 95 percent of patients.”

Keywords: care coordination, care teams, chronic care, collaborative care, colorado, communication, EHR, electronic medical record, health information technology, hospital readmissions, integrated care, Kaiser Permanente, KP healthconnect, patient support, preventive care, skilled nursing facility, telephonic care, transitional 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

Electronic Intervention Program Significantly Improves Care for Patients with Heart Disease

In recognition of the importance of early treatment and intervention for coronary artery disease (CAD), care teams at Kaiser Permanente Colorado created a new electronic care registry and support program called the Collaborative Cardiac Care Service (CCCS). The program’s agreed-upon guidelines and protocols were integrated into their electronic medical record system to guide the care teams at the point of care, as they treated more than 12,000 of their CAD patients.


Excerpted from:
Closing the ‘Treatment Gap’ in Cardiac Care

Coronary Artery Disease (CAD) is the dangerous buildup of plaque inside the coronary arteries. It is the leading cause of death in the United States, affects 80 million Americans, and is one of the top five chronic conditions that drive the vast majority of health care costs.

In recognition of the importance of early treatment and intervention for CAD, care teams in Colorado created a new electronic care registry and support program called the Collaborative Cardiac Care Service (CCCS). The program’s agreed-upon guidelines and protocols were integrated into their electronic medical record system to guide the care teams at the point of care, as they treated more than 12,000 CAD patients.

The CCCS program enrolled every patient who presented with CAD for both short- and long-term care. Using its electronic care registry and electronic medical record system, nurses and clinical pharmacists gained immediate access to comprehensive, reliable, evidence-based patient information at all points of care to enable the support of an individual patient’s care plan, encourage treatment adherence, and coordinate care regardless of setting. Survival rates increased dramatically with an estimated prevention of more than 135 deaths and 260 costly emergency interventions annually.

For more information about the Collaborative Cardiac Care Service, see
http://xnet.kp.org/permanentejournal/sum08/cardiac-care.html

Keywords: CAD, care coordination, care teams, cardiac care program, chronic care, collaborative care, Colorado, communication, coronary artery disease, electronic medical record, evidence-based medicine, health information technology, integrated care, Kaiser Permanente, KP Healthconnect, patient support, population health, preventive care, safety, 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

Primary Care Teams that Include Behavioral Health Specialists Manage Both the Mental and Physical Conditions of Patients

Kaiser Permanente’s Northern California region has integrated behavioral health care within its primary care offices, which improves their patients’ access to mental health services and provides a wider perspective on the patient’s health.

Excerpt from Commonwealth Fund case study:

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

” Each primary care team in Northern California includes a behavioral medicine specialist, who is a licensed clinical psychologist or clinical social worker trained to work in primary care. The behavioral medicine specialist co-manages patients with identified mental health conditions such as depression or anxiety disorders, providing counseling (using proven modalities such as cognitive behavioral therapy or behavioral activation) and problem-solving support individually or in group sessions. The patient’s primary care physician is responsible for medication management. Patients with severe mental health conditions or substance use disorders are referred to psychiatric specialty care or chemical dependency treatment.

Since many patients have co-occurring mental and physical conditions, colocation of behavioral medicine specialists in primary care allows a broad perspective that is superior to disease-specific approaches. It also improves access to mental health care, since many patients prefer to receive such services from their primary care team and may not visit mental health specialists even when referred.

Through its participation in a study of a collaborative care model called IMPACT, the organization learned that outcomes could be enhanced by adopting a more systematic approach to caring for patients with depression. As a result, the region recently began using a population database and a patient-completed questionnaire called the PHQ-9 to track patients’ progress and provide feedback so that the physician and behavioral medicine specialist can tailor treatment to achieve symptom-improvement goals. The region ranks second among health plans nationally on a measure of antidepressant medication management–acute phase treatment, according to the NCQA.”

Link to full case study: http://www.commonwealthfund.org/Content/Publications/Case-Studies/2009/Jun/Kaiser-Permanente.aspx

Keywords: access, behavioral health, care coordination, care teams, chronic care, collaborative care, communication, Kaiser Permanente, behavioral health, mental health, depression, electronic medical record, health information technology, integrated care, Northern California, kp healthconnect, patient support, population health, preventive care, treatment

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