SFHSS - December 2019 Board Meeting - DRAFT V3 · Microsoft PowerPoint - SFHSS - December 2019...
Transcript of 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
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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
3 ©2019 Kaiser Foundation Health Plan, Inc.
A BETTER WAY TO TAKE CARE OF BUSINESSCoordinated & Connected Care for SFHSS Members
Research
Doctors
EHR
Hospitals
Innovation
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A BETTER WAY TO TAKE CARE OF BUSINESSCoordinated & Connected Care for SFHSS Members
Our Electronic Health Record (EHR) Supports Our Complex Care Management Approach
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A BETTER WAY TO TAKE CARE OF BUSINESS
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
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
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A BETTER WAY TO TAKE CARE OF BUSINESS
Health CoachHealth Coach
SpecialistSpecialist
PharmacistPharmacist
NurseNurse
Clinical Health Educator
Clinical Health Educator
Registered Dietician
Registered Dietician
Medical AssistantMedical
Assistant
Program AssistantProgram Assistant
Coordinated & Connected Care for SFHSS Members
Outpatient Care Setting
Patient-Centered and Team-Based Care:Complex Care Management For Those With Multiple Chronic Conditions
Primary Care
7 ©2019 Kaiser Foundation Health Plan, Inc.
A BETTER WAY TO TAKE CARE OF BUSINESSCoordinated & Connected Care for SFHSS Members
Transitions fromInpatient Outpatient Care
Patient-Centered and Team-Based Care:Complex Care Management For Those With Multiple Chronic Conditions
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.
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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
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Chronic Conditions Management Impact:2018 HEDIS Performance
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Chronic Conditions Management Impact:Kaiser Permanente Outpaces Nation in Reducing Deaths from Heart Attacks and Stroke
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A BETTER WAY TO TAKE CARE OF BUSINESS
Appendix
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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
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A BETTER WAY TO TAKE CARE OF BUSINESSNavigation and Advocacy Support
Navigation & Advocacy Support