1. Kaiser Permanente: Supporting Behavior Change
Rio de Janeiro, Brazil
August 16, 2017
Barbara Crawford, MS, RN, NEA-BC
KFHP/H Northern California Vice President, Quality & Regulatory Services

2. Session Objectives
Describe Kaiser Permanente as an organization, including our size, presence and strategy
Understand how we leverage technology to inform care
Share ways in which we define, measure and drive high quality care, and how transparency provides us with a competitive advantage
Understand how we engage patients in their own healthcare improvement
Addressing Total Health

3. Our Mission
To provide high-quality, affordable health care services and to
improve the health of our members and the communities we serve.

4. What is Kaiser Permanente?
Kaiser Permanente is an integrated delivery and financing system comprised of three entities that operate through contracts with one another: the Kaiser Foundation Health Plans, Kaiser Foundation Hospitals, and the Permanente Medical Groups.
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of the leading health care providers and not-for-profit health plans in the United States.
We bring together health care services and insurance coverage.
Most of our health care services are under one roof.
Members have the support of an entire care team.
We are dedicated to care innovations, clinical research, health education and the support of community health. 4

5. Kaiser Permanente $64.6 B 11.8 M 200,000 20,000+ 39 670+ Washington
Colorado
Northwest
California
Mid-Atlantic States
Georgia
Hawaii
$64.6 B
11.8 M
200,000
operating revenue
members
employees
20,000+ 39
670+
physicians
hospitals
medical offices

6. Touching the Lives of Millions of People
care visits – more than half virtually
1 M
mammograms
138,000
inpatient
surgeries
78.3 M
prescriptions filled
458,000
hospital admissions
101,000+
births
1.9 M
colorectal cancer screenings
2015 DATA

7. “We need to have equitable access to higher quality and more affordable health care that gives everyone access to the front door of the American health care system.”
— Bernard J. Tyson, Chairman and CEO

8. Our Strategy
As we move into 2017 and beyond, we will build upon our foundational elements – prepayment, group practice, prevention, population-based approach and information technology – to advance our mission.
Photo:
Sidney Garfield, MD (left): a surgeon, visionary, and trailblazer
Henry J. Kaiser (right): an entrepreneur who revolutionized shipbuilding and started global enterprises, including cement, steel, aluminum, and automobiles 8

9. Northern California Story: Our Starting Point in 2007
A solid foundation
Market leader in Northern California
Broad external recognition for quality and service performance
A deep, shared commitment to the mission of KP
Successful experience in:
Transforming outpatient service, quality and access
Driving system-wide hospital improvement
Challenges
External Pressures: Increased competition, reimbursement risk/fines, more stringent regulations, increased transparency
Significant variation in performance in quality, patient safety, service, efficiency and cost measures
Rising healthcare costs locally and nationally 9

10. Health Insurance Premium Trends in Northern CA
The annual rate of increase of health plan premiums in Northern CA has declined in recent years relative to the early 2000’s.
Sources: Hewitt Health Value Initiative 2005 – 2013, Mercer Employer Survey 2014 – 2015

11. Transparency is a Game Changer
Times Have Changed…
Federal & State Regulations on Public Reporting Have Multiplied
Consumers are demanding transparency in pricing
Quality drives Organizational Value
Value = Quality + Service
Cost
Growing focus on cost & price
Demonstrating value & efficiency of care
Patient & member experience with care & service
All payer claims databases emerging nationally
Extensive reporting to employer groups
Proliferation of healthcare exchanges

12. The Benefits of Transparency
Kaiser Permanente challenges its competitors to have a more formal commitment to public reporting and transparency
Benefits of Transparency
Allows demonstration of “best”
Motivates improvement
Raises the bar on accountability
Enables learning
Increases recognition of risk
Provides information for decision-making
Dimensions of Transparency
Internal
Between clinicians and patients
Among clinicians
Organization-wide
External
Among institutions
Public reporting
Key Stakeholders
Individual consumers and employers
Providers and practitioners
Health plans
State/federal regulators and accreditors

13. KP’s Approach to Transparency & Reporting
Technology is the “Key Enabler” to Optimize Quality & Costs
The Big “Q”
A web-based dashboard to track medical center and service area performance against external benchmarks & internal goals
KP Insight
A web-based data reporting system that trends quality and cost measures to internal goals & benchmarks
KP HealthConnect
KP’s electronic medical record – monitors & tracks clinical performance, patient outcomes & promotes adherence to evidenced based practice through robust decision support tools & analytics

14. Transparency: Integrated Clinical Information Systems
KP Health Connect enables member engagement, which produces superior medical outcomes.
CarePoint
Population Management Tool
Labs
Inpatient
Outpatient
Emergency
Pharmacy
Imaging
Immunization
Membership
Financial & Benefits
KP Health Connect
Secure Web-Based
Universal Access
Real Time
Linked to Delivery System
Electronic Ordering
Digital Imaging
Secure Messaging
Disease registries
Risk stratification
Identification of subgroups needing care
Patient management tools
Targeted panel lists
Inreach- prompts, reminders for clinicians
Outreach- Letters and automated telephone outreach to members
Monitoring and process improvement measures and reports
At Kaiser Permanente, patient care is highly coordinated through state-of-the-art technology and multispecialty physician group practice.
kp.org and
My Health Manager
L&T Forum Complete - Cappiello OTN 29865 14 14 14

15. Transparency: Access to Medical Records
For Clinicians
For Patients
Review entire medical records
Check lab results
Immunization records
History of medical visits
Direct ordering of prescriptions, labs and referrals
Best practice alerts
See summary of medical record
See lab results with explanations
See immunization records with advice
Order and refill prescriptions
any provider you have seen recently (video visits are becoming available)
KP HealthConnect and kp.org allow clinicians and patients, respectively, to easily access medical records.

16. Transforming Care Beyond the Hospital
As a prepaid Health Maintenance Organization, it’s in KP’s DNA to support patient self-care
“The patient is the most important primary care provider”
Built systems & infrastructure to proactively identify & support patients to lead healthy lifestyles and manage chronic conditions
Outpatient “Vital Signs”
Outreach & In-reach
Person-centric support for healthy living
My Doctor Online [kp.org/mydoctor]
Transforming Care Beyond the Hospital
As a prepaid Health Maintenance Organization, it's in KP's DNA to support patient self care.    We sometimes say " the patient is the most important primary care provider"
We build into our systems ways of identifying and supporting our patients to support healthy lifestyles and help them manage their chronic conditions.
We build trainings and resources using motivational interviewing and brief negotiation theories.  These rely on the patient to identify their core values and motivation to craft their own strategies for healthy changes
In outpatient clinic visits when the patient is lead to the exam room, we ask questions as part of our "Vital Signs" -- Do you smoke?  How many days do you exercise and for how long?  How much alcohol do you drink a week on average?  This presents opportunities for physician conversations and referral to other resources
We do both outreach -- identifying patients who need preventive services and contacting them -- and in-reach -- offering patients who are in our offices services like mammograms on the spot
We can refer patients to a large variety of resources to support healthy living -- in print, in person and on line classes, one on one counseling, wellness coaching and more.
 In NCal, our robust physician home pages, My Doctor Online [kp.org/mydoctor] include excellent, physician vetted information, interactive online tools, and videos that help support the patient's health journey 

17. Creating Health Care Value at Kaiser Permanente
Several strategic elements for creating health care value at KP have been employed, and as a result we have seen improvements in the quality of care we provide

18. Supporting Patient Behavior Change
Motivational Interviewing (MI) Training While general trainings are scheduled throughout the year, KP has developed tailored intensive MI trainings for the following programs to support quality goals and overall patient engagement and adherence to:
Family Violence Prevention
Cancer Care
Tobacco Cessation
Teen Pregnancy Counseling
Colorectal Cancer Screening
Complex Chronic Conditions (CCC)
Wellness Coaching Center
Healthy Weight
Pediatric Weight
Life Care Planning
Depression
Special Needs Plan (SNP)
Schmittdiel, J A, Adams, SR, Goler, N, et al. The impact of telephonic wellness coaching on weight loss: A “Natural Experiments for Translation in Diabetes (NEXT-D)” study. Obesity, 25: 352–356. doi: /oby.21723
Boccio M, Sanna RS, Adams SR, et al. Telephone-based coaching: a comparison of Tobacco Cessation Programs in an integrated health care system [published online ahead of print November 11, 2015]. Am J Health Promot. doi: /ajhp QUAN-424. 18

19. Prevention: The Tobacco Burden
Tobacco is responsible for one in five deaths in the US, around 500,000 deaths each year
US tobacco use costs the healthcare system an estimated $100 billion per year.
What you can do:
Advise
Provide coaching
Provide medication support
By December 31, 2015:
Quitters
Schmittdiel, J A, Adams, SR, Goler, N, et al. The impact of telephonic wellness coaching on weight loss: A “Natural Experiments for Translation in Diabetes (NEXT-D)” study. Obesity, 25: 352–356. doi: /oby.21723
Boccio M, Sanna RS, Adams SR, et al. Telephone-based coaching: a comparison of Tobacco Cessation Programs in an integrated health care system [published online ahead of print November 11, 2015]. Am J Health Promot. doi: /ajhp QUAN-424.

20. Tobacco Cessation Approach –
KP developed a comprehensive tobacco cessation & prevention strategy that includes:
Systems integration: treatment decision support and screening reminders in the EMR
Evidence-based patient education and behavior change support through coaching, classes, and online tools (no additional costs or limits for members)
Outreach strategies to monitor patients, prevent relapse, or re-connect with support
Clinical guidelines and training support
Social marketing campaign (50,000 Quitters) to engage patients and staff
Outcomes –
Over 100,000 Quitters in past 4 years
Steady decrease in prevalence (KP population is approximately 27% below state prevalence. CA is one of 2 states to have reached Healthy People 2020 goal of less than 12% prevalence)
Schmittdiel, J A, Adams, SR, Goler, N, et al. The impact of telephonic wellness coaching on weight loss: A “Natural Experiments for Translation in Diabetes (NEXT-D)” study. Obesity, 25: 352–356. doi: /oby.21723
Boccio M, Sanna RS, Adams SR, et al. Telephone-based coaching: a comparison of Tobacco Cessation Programs in an integrated health care system [published online ahead of print November 11, 2015]. Am J Health Promot. doi: /ajhp QUAN-424.

21. DOR Study: Quit Rate 31% vs Control 23%
Wellness Coaching participants quit tobacco and filled tobacco cessation medication prescriptions at a comparable rate to tobacco cessation class participants and a statistically significantly higher rate than a matched control group.

22. Wellness Coaching Center
Smoking cessation
Healthy weight
Healthy eating
Exercise
Stress management
Remote regional Call Center program by Health Educators
Telehealth for personalized care and convenient hours
Motivational interviewing to assess readiness and co-create action plan
Since 2010, WCC has coached
26,000 patients in 65,000 visits
Wellness Coaching Center: 5 key areas; Smoking cessation, Healthy Weight, Healthy eating, Exercise and Stress management. Also provided in Spanish. Coaching is based on motivational interviewing based conversations which helps to evoke internal motivation, affirm past success and attempts to change, assess readiness for change, and co-creates a realistic plan. Since 2010, we have coached 26,000 patients in 65,000 visits.

23. Diabetes Care Bilingual Site (kp.org/mydoctor/diabetes)
Toggle between English and Spanish
Links up to Videos, Patient Stories, Fotonovelas, Infographic Article
Helps patients stay on track
All diabetes care team members also received “Speak My Culture” for Latino care
Bilingual Site (kp.org/mydoctor/diabetes)

24. FIT: Effective Centralized Outreach
PCP Pre-letter
FIT Kit
Robocall Reminder
Reminder Letter
Colorectal Cancer Screening - Applied behavioral science
Regional outreach: Patient-tested messages within physician letters, small-media postcards, robocalls, and s
Medical center outreach: Brief motivational interviewing phone calls to patients
Medical center in-reach: Culturally tailored scripts and messages
72% of patients return FIT Kit

25. Delivering Culturally Competent Care in Primary Care
108
My Doctor Online Articles in English and Spanish 85
infographics in Spanish & English 30
Physician videos in Spanish & English 40
Photo-story/Fotonovelas/Videos/Booklets 31
How-to-videos in English & Spanish

26. Culturally Responsive FIT Outreach
Feb 2016
Latino Outreach
Q1 2017
AA Outreach
Launched in Feb 2016
Fotonota style
Cost effective
Increase 1.2% FIT return rate
Reduce disparity gap by 16.8%

27. Pediatric Prospects for a Healthier Tomorrow
Comparing BMIs from to those from , for ages 2-19 years: #4
% Overweight decreased 11.1%
% Obese decreased 3.6%
EMR auto-populates educational materials based on behavior change principles for nutritional and physical activity in the After Visit Summary
2016 HEDIS Performance Rank
BMI documentation #4
Counseling for nutrition #6
Counseling for physical activity #6
Weight and height are measured at least annually, starting at age two
Electronic Medical Record (EMR) auto-populates educational materials (based on Behavior Change principles) for nutrition and physical activity in the After Visit Summary
3 Pediatric weight management measures nationally ranked in Top 10 for HEDIS 2016
Measure Rank
BMI percentile documentation 4th
Counseling for nutrition 6th (up from 7th rank)
Counseling for physical activity 6th 27

28. Leverage Technology to Increases Member Engagement for Prevention Care
Current test data shows approx % of patients who see the eAlert book an appointment
My Doctor Online app also allows patient to directly book their Cervical Cancer and Breast Cancer Screening appointments
They can also get more information on how to get vaccines 28

29. Supporting Members to Lead Happier, Healthier Lives
All KP Medicare and commercial plans were rated highest (or tied for highest) in all areas we serve in NCQA study.
In 2017, KP members in 6 geographic areas rate KP
highest in satisfaction in the J.D. Power Member Health Plan Study. Also, KP members rate KP highest in 2016 JDP Medicare Advantage study.
15 Kaiser Permanente facilities honored in 2015 as ‘Top Performer’ for Quality
and Safety by The Joint Commission.
Accolades:
Supporting Members to Lead Happier, Healthier Lives
In 2017, for the 7th year in a row, KP has earned the PQA’s Excellence in Quality Award for medication safety and appropriate use.
In 2016, for the 9th straight year, KP is the only plan in California to earn the 4-star rating for overall quality of care in OPA’s Healthcare Quality Report.
In 2016, 37 KP medical centers continue to be Stage 7 Award winners, recognized for successful electronic health record implementation
Five Kaiser Permanente regions received 5-Star ratings for 2017 Medicare plans, the highest possible rating.
In 2016, for the 4th year in a row, KP’s California health plans received top rating for quality and service.
In 2017, for the 7th year in a row, Kaiser Permanente received Satmetrix’s highest customer loyalty ranking in the health insurance category.
Is it a coincidence that Kaiser Permanente has been ranked highest in customer satisfaction for eight consecutive years (according to the J.D. Power Health Plan Member Survey) – the same eight years that members have been able to use our online features?
In 2015, KP was honored with Leapfrog’s inaugural “Living the Vision” award for excellence.

30. Q+A