sfhss - december 2019 board meeting - draft v3 · microsoft powerpoint - sfhss - december 2019...

1 ©2019 Kaiser Foundation Health Plan, Inc. ©2019 Kaiser Foundation Health Plan, Inc. All Rights Reserved.

Kaiser Permanente Complex Care ManagementDecember 12, 2019

SFHSS HSB Meeting

2 ©2019 Kaiser Foundation Health Plan, Inc.

A BETTER WAY TO TAKE CARE OF BUSINESS

Today’s Discussion:

• Coordinated & Connected Care

• KP’s Electronic Health Record (EHR) Supports Our Complex Care

Management Approach

• Complex Care Management – Inpatient

• Complex Care Management - Outpatient


A BETTER WAY TO TAKE CARE OF BUSINESSCoordinated & Connected Care for SFHSS Members

Research

Doctors

EHR

Hospitals

Innovation



Our Electronic Health Record (EHR) Supports Our Complex Care Management Approach



Outpatient Care Setting

Coordinated & Connected Care for SFHSS Members

Transitions from Inpatient Outpatient Care

Patient-Centered and Team-Based Care:Complex Care Management For Those With Multiple Chronic Conditions

Health CoachHealth Coach

SpecialistSpecialist

PharmacistPharmacist

NurseNurse

Clinical Health

Educator

Clinical Health

Educator

Registered Dietician


Medical AssistantMedical

Assistant

Program AssistantProgram Assistant

Primary Care

Hospital-Based

RN Patient Care

Coordinator

OutpatientOutpatient

Inpatient Rehabilitation

Inpatient Rehabilitation

Home HealthHome Health

Skilled Nursing Facility

Skilled Nursing Facility

RN Patient Care Coordinator



Health CoachHealth Coach

SpecialistSpecialist

PharmacistPharmacist

NurseNurse

Clinical Health Educator

Clinical Health Educator



Medical AssistantMedical

Assistant

Program AssistantProgram Assistant

Coordinated & Connected Care for SFHSS Members

Outpatient Care Setting


Primary Care



Transitions fromInpatient Outpatient Care


Hospital Based RN Patient Care Coordinator in

coordination with HBS and Primary Care

Outpatient• Transitions Team calling those with high readmission risk in 48hrs

• Outpatient rehabilitation services• Link to PCP & Outpatient Teams• Specialty Care• Pharmacy Reconciliation

Outpatient• Transitions Team calling those with high readmission risk in 48hrs

• Outpatient rehabilitation services• Link to PCP & Outpatient Teams• Specialty Care• Pharmacy Reconciliation

Inpatient RehabilitationInpatient Rehabilitation

Home Health• Nurse• Physical Therapy• Occupational Therapy• Speech Therapy

Home Health• Nurse• Physical Therapy• Occupational Therapy• Speech Therapy

Skilled Nursing FacilitySkilled Nursing Facility

RN Patient Care Coordinator

All patients receive printed discharge instructions at the time of discharge from the hospital or emergency room.

This includes: education about a patient’s condition and precautions, appropriate contact information if questions or concerns arise, and information about scheduled follow-up appointments.


Diabetes Measure Star Rating

Glucose Control

Eye Exams

Statin Therapy

Blood Pressure Control

Heart Disease Measure Star Rating

Controlling high blood pressure

Patients with cardiovascular disease – statin therapy

5

5

5

5

5

5

Chronic Conditions Management Impact:2018 HEDIS Performance


Chronic Conditions Management Impact:Kaiser Permanente Outpaces Nation in Reducing Deaths from Heart Attacks and Stroke



Appendix


Connecting To Care:Digital Health Resources For Our Members And Their Family

It’s easy to manage your healthcare…

Secure message your care team

Make appointments

View lab results and your health history

Proxy access for family members

...and stay on top of medications

• View your medications

• Set reminders

• Refill Prescriptions

My Doctor Online

My KP Meds


A BETTER WAY TO TAKE CARE OF BUSINESSNavigation and Advocacy Support

Navigation & Advocacy Support

sfhss - december 2019 board meeting - draft v3 · microsoft powerpoint - sfhss - december 2019...

Documents