Kaiser offers integrated, coordinated patient care

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By Dr. Richard Spurlock

Individuals and employers alike are navigating a complex health care system these days. In Colorado Springs, Kaiser Permanente is working to address this complexity head-on as it incorporates technology, evidence-based research and collaborative care teams to provide high-quality, coordinated patient care.

Kaiser Permanente is unique in that it is both an insurance company and a health care provider. The nonprofit health plan has had a presence in Southern Colorado since 1997, with 56,000 members currently living in the community. These members have access to a network of nearly 800 primary and specialty care physicians, along with Kaiser Permanente physicians at medical offices in Pueblo and Briargate Senior Health Center in Colorado Springs.

Kaiser Permanente’s integrated care-delivery system extends beyond the four walls of an exam room. In Southern Colorado specifically, the health plan is offering several new programs designed to streamline hospital and outpatient care.

Hospitalist program

One such program is Kaiser Permanente’s Hospitalist program at Memorial Central and Memorial North hospitals. Primary care physicians do not typically see patients while they are in the hospital. Instead, they delegate care of their hospitalized patients to hospitalists. As the name implies, hospitalists are board-certified internal medicine or family medicine physicians who specialize in caring for patients in the hospital. Four Kaiser Permanente physicians serve as staff hospitalists at both Memorial hospitals seven days a week.

Hospital-based care is not new to Kaiser Permanente in Colorado, as its physicians have provided this type of inpatient care for almost 25 years. The distinct advantage of the Hospitalist program at the Memorial hospitals is that it provides a direct line of communication between hospital staff and Kaiser Permanente providers to view and communicate patient information electronically.

Hospitalists send patient discharge reports to primary care physicians in real time, even before the patient leaves the hospital. This helps align follow-up treatment with the care received in the hospital.

“Our staffing model is designed to ensure more time per patient than the national average, giving us at least 10 hours at the hospital each day,” said Dr. Kelly Foley, Kaiser Permanente’s assistant regional department chief of hospital medicine in Southern Colorado.

“As a result, we have time to determine how we can best support patients and their families during their hospital stays and after they are discharged. We have a direct line to all Kaiser Permanente services and can easily refer patients when we identify a particular need.”

Another component of the integrated care delivery system is Kaiser Permanente Care Connections (KPCC). Offered at no additional charge to members, KPCC features nine nurses, two medical assistants and a disease management coordinator. Their work includes helping members manage chronic conditions, wellness coaching, assistance in accessing preventive care and transitioning care from the hospital to outpatient settings. Approximately 3,000 Kaiser Permanente members access KPCC services each month.

According to Dawn Wainright, RN, BSN, KPCC collaborative care coordinator, “We know that coordinated patient care improves health outcomes and reduces costs. By working in partnership with primary care physicians, KPCC staff are able to identify gaps in care and connect members to services they need to achieve their best health.”

A direct example is KPCC’s approach to identifying and supporting members with uncontrolled diabetes:

1. Staff begin by using data derived from Kaiser Permanente’s HealthConnect® electronic medical record to contact members who have uncontrolled diabetes (hemoglobin A1C levels of 8 or higher).

2. Members are then contacted via email and phone to identify any barriers to adhering to their medications or making healthy lifestyle choices. KPCC staff develop a care plan for members, which is shared and implemented with their primary care physicians.

3. Long-term, KPCC staff work with members to reinforce messages they receive from their physicians and connect them to community resources. Members are also able to attend diabetes management classes led by Kaiser Permanente dietitians. Since these classes began in early 2012, 47 percent of participating individuals have achieved greater control of their blood sugar.

“KPCC is designed to educate our members on what’s available and more importantly, offer hope and care,” said Donna Calhoon, RN, KPCC collaborative care coordinator. “All too often, patients don’t know who to ask for help. That’s where the KPCC staff come in, to serve as their long-term partner in health.”

Coordinated health care depends on patients, providers and care teams working together. For employers, it results in reduced health care costs and more productive employees. For individuals, it helps them stay out of the hospital and live longer, healthier lives.

“The KPCC program literally saved my life,” said Debbie Torrez, Kaiser Permanente member from Colorado Springs. “I am a diabetic and when I found out about the program I wasn’t doing well. Donna and her team helped me get the medication I needed, connected me with doctors and followed up to see how I was doing. I urge others to seek out KPCC because they are truly here to help.”

Dr. Richard Spurlock, who has a master’s in business administration, is the medical director for Kaiser Permanente in Southern Colorado and a part of the Colorado Permanente Medical Group.