Complete Care program improves outcomes for Kaiser Permanente patients

Complete Care, a collaborative approach to meeting patient needs, is improving outcomes for Kaiser Permanente patients. Results from the program are featured in the November 2013 issue of The Joint Commission Journal on Quality and Patient Safety, and described in a journal editorial as, "a dramatic and impressive example of what is possible with a carefully designed and implemented system-level intervention."

"Complete Care leverages Kaiser Permanente's technology, our integrated system, and our dedicated care teams to ensure that patients with complex chronic conditions receive the proactive support, coordinated care, and follow up they need to maintain optimal health," said Michael Kanter, MD, regional medical director of quality and clinical analysis, Southern California Permanente Medical Group, and lead author for the article.

Kaiser Permanente is committed to improving the quality of care across all of its regions, and in 2005 the organization launched the Complete Care model in Southern California with the goal of transforming care for healthy members as well as members with chronic conditions and multiple health issues.

The design of Complete Care is based on the Chronic Care Model, which originated from a combination of scientific literature undertaken by The MacColl Institute for Healthcare Innovation in the 1990's. Complete Care is also rooted in an analysis of best practices in coordinated care for patients with chronic conditions such as asthma, diabetes and hypertension and extends this model to prevention and wellness. Complete Care has helped Kaiser Permanente create rare disease programs for patients with Down Syndrome, spinal cord injuries, and Amyotrophic Lateral Sclerosis (commonly known as Lou Gehrig's disease), and is flexible enough to allow for management of most conditions seen in an outpatient setting. It works in conjunction with care management programs, which promote exercise, obesity management, screen for aortic aneurysms, and alcohol overuse.

Bringing together the power of the electronic health record system, Kaiser Permanente HealthConnect-, and the care management outreach approach that empowers clinicians and staff to better utilize the one-on-one time they have with each patient, Complete Care includes the practice of "Proactive Office Encounters (POE)."

"Proactive Office Encounters ensure that no matter where patients access care, we are able to address all of their health care needs through a personalized, evidence-based approach. Our goal is to help patients get and stay healthy," said Dr. Kanter.

The POE involves all health care team providers-physicians, receptionists, medical assistants, nurses and pharmacists -- to address patient needs. Using electronic checklists customized to each patient, support staff is able to proactively identify "care gaps" - such as the needs for screenings and other preventive care. Caregivers proactively contact patients to encourage them to address these gaps.

During these conversations, clinicians help patients schedule preventive care screenings, provide medication adherence and health education information, and remind them to keep the follow up appointments that will help them achieve their own best health. Bringing the entire care team into this process has improved the consistency of preventive care, the quality of chronic conditions care, and reliability of staff support for physicians. It also motivates staff to respond while they have the attention of a receptive patient.

Over the past six years Kaiser Permanente has shown steady improvement in its quality scores as reported by the Healthcare Effectiveness Data and Information Set (commonly referred to as HEDIS-), a set of 51 publicly reported quality metrics. Specifically, in Southern California, Kaiser Permanente improved an average of 13 percent as compared to 5.5 percent for the average health plan, according to Quality Compass, a comprehensive national database for the National Committee for Quality Assurance. Across all of its regions, Kaiser Permanente ranked in the top 10th percentile for many of the measures tracked and leads the nation with the most number 1s in HEDIS- Commercial and Medicare measures.