Complete care improves patient outcomes

"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 1990s. 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."

"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 need 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.