Behavior medicine specialist.

Total Health is a vision for the future and a strategy to prevent preventable disease, save lives, and make health care more affordable. Total Health means health of mind (behavior health) and health of body (physical health). To achieve Total Health we need healthy people in healthy communities.

Adaptation of a Published Risk Model to Point-of-care Clinical Decision Support Tailored to Local Workflow.

Electronic clinical decision support can bring newly published knowledge to the point of care. However, local organizational buy-in, support for team workflows, IT system ease of use and other sociotechnical factors are needed to promote adoption. We successfully implemented a multi-variate cardiac risk stratification model from another institution into ours.

Association of patient-reported care coordination with patient satisfaction.

Little is known about the relationship between care coordination directly assessed from the patient's perspective and patient satisfaction. This study applied multiple logistic regression models to examine associations between patient-reported care coordination and patient satisfaction among 1367 patients with diabetes. We found robust positive relationship between care coordination and patient satisfaction with overall chronic care (odds ratio [OR] = 1.

Upstream discussion provided in the ambulatory setting to assist patients with chronic kidney disease considering dialysis.

Objectives: Extensive discussion with renal patients about treatment intensity is not systematically integrated into their care and often occurs during an acute hospitalization. We conducted a "test-of-change" pilot study to assess the utility of providing an upstream discussion in the ambulatory setting as an additional nephrology consult to assist patients with chronic kidney disease considering treatment choices.

Methods: We randomly assigned patients with Stage 4 or Stage 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups.

The next step towards making use meaningful: electronic information exchange and care coordination across clinicians and delivery sites.

Background: Care for patients with chronic conditions often requires coordination between multiple physicians and delivery sites. Electronic Health Record (EHR) use could improve care quality and efficiency in part by facilitating care coordination.

Objective: We examined the association between EHR use and clinician perceptions of care coordination for patients transferred across clinicians and delivery sites.

Healthy behavior change in practical settings.

The core principle of implementing healthy behavior change is making the healthy choice the easy choice. Putting this motto into practice requires us to remove the barriers that individuals face when trying to live a healthy lifestyle. It is important to look at the bigger picture when helping our patients reach optimal health, looking closely at exercise levels and home life.

Prediabetes and lifestyle modification: time to prevent a preventable disease.

More than 100 million Americans have prediabetes or diabetes. Prediabetes is a condition in which individuals have blood glucose levels higher than normal but not high enough to be classified as diabetes. People with prediabetes have an increased risk of Type 2 diabetes.

Treatment progress indicator: application of a new assessment tool to objectively monitor the therapeutic progress of patients with depression, anxiety, or behavioral health impairment.

Depression, anxiety, and behavioral health impairment are common in the US. Efforts to treat patients with depression, anxiety, and chemical dependency are surpassed by the great demand for psychiatrist and therapist appointments. Unlike other specialties, psychiatry lacks a vital sign or tests (eg, blood pressure for hypertension and hemoglobin A1c for diabetes) to objectively measure a patient's response to therapy.

Manual and automated methods for identifying potentially preventable readmissions: a comparison in a large healthcare system.

Background: Identification of potentially preventable readmissions is typically accomplished through manual review or automated classification. Little is known about the concordance of these methods.

Methods: We manually reviewed 459 30-day, all-cause readmissions at 18 Kaiser Permanente Northern California hospitals, determining potential preventability through a four-step manual review process that included a chart review tool, interviews with patients, their families, and treating providers, and nurse reviewer and physician evaluation of findings and determination of preventability on a five-point scale.

Physician update: total health.

As an integrated prepaid health care system, Kaiser Permanente (KP) is in a unique position to demonstrate that affordability in health care can be achieved by disease prevention. During the past decade, KP has significantly improved the quality care outcomes of its members with preventable diseases. However, because of an increase in the incidence of preventable disease, and the potential long-term and short-term costs associated with the treatment of preventable disease, KP has developed a new strategy called Total Health to meet the current and future needs of its patients.

Person-focused care at Kaiser Permanente.

Patient-focused care has been described as an extension of patient-centered care, recognizing that patients’ medical needs are best understood and addressed in the context of their entire lives, including their life goals and social, economic, emotional, and spiritual functioning. Kaiser Permanente is expanding its ability to care for members as whole persons, not just as patients, with sensitivity to nonmedical factors in planning and delivering care. We describe emerging examples in several areas: interdisciplinary care planning, behavior change, social care, patient-reported outcome measures, and Total Health.

Complex case conferences associated with reduced hospital admissions for high-risk patients with multiple comorbidities.

Objectives: Reducing avoidable hospital readmissions presents an opportunity to improve health care quality and reduce avoidable costs. We studied the effect person-focused care may have on reducing avoidable admissions to the hospital.

Methods: Among patients with heart failure discharged from the hospital, we evaluated the effect on 30-day readmissions of transitions-in-care interventions: home health visits, follow-up phone calls, and physician office visits.

[The QALY approach - potentials and limits].

The concept of quality-adjusted life expectancy ("quality-adjusted life years", QALY) is a type of cost-benefit analysis for health economic evaluation of treatment options. The two parameters quality of life and life expectancy are thereby combined into a single value - the QALY - which can shed light on the cost of therapy per additional quality-adjusted year of life. The concept is, however, widely used in ethical discussions of the adequacy of the generalizations on which this approach is based.

Choosing wisely and beyond: shared decision making and chronic kidney disease.

In 2012, the Kaiser Permanente Area Medical Directors of Quality decided to sponsor analytic activities to improve shared decision making for patients with chronic kidney disease. The objective was to move shared decision making for renal replacement therapy or maximal conservative management upstream rather than waiting until the patient presented to the emergency room requiring acute dialysis. Nephrologists have multiple opportunities to discuss treatment options with patients throughout the course of their disease.

The readmission reduction program of Kaiser Permanente Southern California-knowledge transfer and performance improvement.

In 2011, Kaiser Permanente Northwest Region (KPNW) won the Lawrence Patient Safety Award for its innovative work in reducing hospital readmission rates. In 2012, Kaiser Permanente Southern California (KPSC) won the Transfer Projects Lawrence Safety Award for the successful implementation of the KPNW Region's "transitional care" bundle to a Region that was almost 8 times the size of KPNW. The KPSC Transition in Care Program consists of 6 KPNW bundle elements and 2 additional bundle elements added by the KPSC team.

Use of IndiGO individualized clinical guidelines in primary care.

Objective: To determine if IndiGO individualized clinical guidelines could be implemented in routine practice and assess their effects on care and care experience.

Methods: Matched comparison observational design. IndiGO individualized guidelines, based on a biomathematical simulation model, were used in shared decision-making.

Living with advanced illness: longitudinal study of patient, family, and caregiver needs.

Background And Objectives: Inpatient palliative care (IPC) consults are associated with improved quality of care and less intensive utilization. However, little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve or how effectively those needs are addressed. The objectives of this study were 1) to summarize findings in the literature about the needs of patients with advanced illness and the needs of their families and caregivers; 2) to identify the primary needs of patients, families, and caregivers across the continuum of care from their vantage point; and 3) to learn how IPC teams affect the care experience.

How Kaiser Permanente uses video ethnography of patients for quality improvement, such as in shaping better care transitions.

Keeping patients and caregivers at the center of quality improvement is critical. Kaiser Permanente's Care Management Institute adapted video ethnography to achieve this aim, using video to capture interviews with-and observations of-patients and caregivers, identify patient-centered improvement opportunities, and communicate them effectively to clinical and administrative leaders and front-line staff. This method is particularly effective for helping understand the needs of frail elders, patients nearing the end of life, those with multiple chronic conditions, and other vulnerable people who are not well represented in focus groups and patient advisory councils.

[Market and competitive positioning of specialized practices: competitive advantages through strategic productivity planning].

The provision of outpatient services will be confronted by increased market concentration. Under these circumstances, individual medical practices are predicted to have a minimal chance for survival since by nature the specialized physician can only accommodate the considerably heterogeneous needs of the patients up to justifiable limits. Due to patients' higher rate of mobility in the elective process, specialty physicians in rural areas are obliged to transform their practices into professional service enterprises.

[The impact of health economics: a status report].

"Health is not everything, but without health, everything is nothing" (cited from Arthur Schopenhauer, German philosopher, 1788-1860). The relationship between medicine and economics could not have been put more precisely. On the one hand there is the need for a maximum of medical care and on the other hand the necessity to economize with scarce financial resources.

Rapid spread of complex change: a case study in inpatient palliative care.

Background: Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program.