Proactive Encounter One Step Ahead

Proactive Encounter 

One Step Ahead: Optimal Integrated Care 

for Every Patient Encounter 

Michael H. Kanter, MD, SCPMG Medical Director of Quality and Clinical Analysis 

Kristen Andrews, Proactive Care Group Leader, SCPMG Clinical Operations 

Southern California Permanente Medical Group 

January 2010

Goal 

Proactive Office Encounter: 

The project aims to improve the consistency and 

quality of preventive and chronic care by; 

• Activating ALL members of the healthcare team in 

providing a proactive patient care experience, 

• Embedding processes to support preventive and 

chronic care needs into standard workflows, and 

• Utilizing information technology tools for 

identification of patient care gaps. 

2 

Confidential & Proprietary

Target Population 

• All members in KPSC 

• Every outpatient encounter, including 

specialty clinics – Approximately 12 

million visits annually 

• Future plan: Proactive Inpatient 

Encounter and Call Center POE 

(Every patient, Every visit, Every time) 

3 


Session Objectives 

Identify opportunities to create a highly reliable care process 

that will lead to: 

• Improved quality and patient care experience 

• Fewer missed opportunities to improve preventive care and chronic 

disease management 

• Increased efficiency 

• Optimal Clinician support in specialty care as well as primary care 

• Strategies to have specialty care departments provide primary 

prevention and cancer screening. 

Apply similar workflows/tools that will result in an increased 

partnership leading to: 

• Consistent support to physician practice, 

• Panel ownership and performance 

• Empowered and engaged staff 

• Better partnership between physician and health care team 

4 


Presentation Agenda 

• Development of Proactive Office Encounter (POE) 

Strategy 

• Tools that support the workflow 

• POE Data 

• Future POE work 

5 


Let’s make it personal. 

6 


Proactive Encounter Patient Story 

• Dale Gordon, Kaiser Permanente member 

7 


Making the Business Case 

Opportunities for Breast Cancer and Diabetes Management 

in Adult Primary Care 

Test 

Total 

Seen in 

Primary Care 

% 

Needing 

Mammogram 

Needing A1c 

test 

47,294 18,222 38% 

10,530 3,911 37% 

• Difficult to reach success if we only focus on Primary Care 

• Approximately 60% of our members are seen in Specialty Care where 

we have an opportunity to close these and other Care Gaps 

8 


Clinical Outcome 

- Hospitalizations reduced; deaths avoided 

METRIC 

% 

Increase 

Lives Saved Per Decade 

Cholesterol Control 17.5% 1406 Lives 

Blood Pressure Control 36.2% 4972 Lives 

HbA1C < 9.0 8.7% 823 Lives 

Smoking Cessation 14.0% 787 Lives 

Breast Cancer Screening 11.6% 

580 Lives 

Cervical Cancer Screening 6.0% 39 lives 

Colon Cancer Screening 25.7% 4075 lives 

TOTAL 

12,684 Lives Saved 

9 


Proactive Encounter embodies our 

integration strategy. 

10 

Integration is our strength and what sets us 

apart from the competition. 


Partnership to Performance: 

Expected Outcomes 

11 

• Highly reliable care 

process 

– Improved quality 

– Fewer missed 

opportunities 

– Increased efficiency 

– Technology supports 

workflow 

– Industry-leading 

performance 

– Optimal MD support 

Confidential & Proprietary 

• Partnership 

– Physician and health 

care team 

– Consistent support 

to physician practice 

– Panel ownership and 

performance 

– Staffing supports 

model 

– Empowered and 

engaged staff

Proactive Encounter Experience 

Pre Encounter 

Proactive 

Identification 

• Identify missing 

labs, screening 

procedures, access 

management, kp.org 

status, etc. 

• Provide member 

instructions prior to 

visit 

• Contact member and 

document encounter 

in KP 

HealthConnect 

Office Encounter 

Office Encounter Management 

• Vital sign collection / 

documentation 

• Identify and flag alerts for provider 

• Room and prepare patient for 

necessary exams 

• Pre-encounter follow-up 

Proactive Office Support 

• Phone calls 

• Letters 

• E-mail 

• Inbox Management 

Post Encounter 

Immediate 

• After visit summary, 

after care 

instructions, followup 

appointments, 

Health Ed materials, 

how to access info 

on kp.org 

Future 

• Follow-up contact 

and appointments 

per provider 

12 


Intervention Design 

- Key elements 

• Processes for staff to fill care gaps for all patients 

• Screenings 

– Pap, Mammogram, FOBT, DEXA 

• Lab Reminders 

– A1c, Microalbumin, LDL, Chlamydia 

• Immunizations 

– Flu, Pneumovax, Pediatric Immunizations 

• Chronic Conditions (DM, HTN, Persistent Asthma) 

– Retinal exam, shoes off for foot exam, glucose meters, health ed classes 

– Blood pressure measurements 

– Asthma questions to determine if patient is “in control” 

• Body Mass Index 

– Height and weight 

• Smoking inquiry 

13 


Overview of 

Proactive Encounter Tools

Building Blocks of Proactive Care 

Performance 

Improvement 

Measuring Performance 

Train/Validate Skills of All Staff 

Physician Preference Sheet 

Specialty Specific Work Flows 

Standard Medical Office Work Flows 

15 


Proactive Encounter Work Flows 

Standard Work Flows 

• Improve Quality 

• Improve Efficiency 

• Improve Physician support 

• For medical office visit 

• Supplemented by Specialty Specific Work Flows 

Work Flow Tools 

16 

• Standard POE Work Flows 

• Team Agreements 

• Video Tutorials 

• Job Aids 

• Proactive Care Booklet 


Standard 

Work Flow 

17 


Proactive Office Encounter 

Team Agreement 

For Provider – MA/LVN/RN 

“Our Cause is Health. Our Passion is Service. We’re Here to Make Lives Better” 

Provider: Medical Assistant/LVN/RN: Meeting Date: _______________________ 

We share responsibility for providing an outstanding care experience for our members, outstanding clinical care, outstanding performance in panel 

management/clinical goals, outstanding performance as a partner team/team member, and an outstanding working experience for our team. 

Ground Rules for Team Agreement Meeting 

This team agreement serves to enhance communication between the provider and medical assistant, LVN, or RN. During this meeting, we 

ask that team members treat each other with respect and remain open to new ideas. Use positive verbal and nonverbal feedback by asking 

rather than demanding. This is an opportunity for each team member to express their needs clearly. It should be based on a collaborative 

approach versus a “top-down” approach. 

Instructions: 

1. Meet together and determine what is important to your practice. 

2. Review “sample” team agreement and use as a guideline for your meeting. 

3. Below are statements that allow you to discuss your role(s) as it relates to POE. Discuss your roles using the sample document to assist you. 

4. Review and revise at agreed intervals. This living document serves to clarify the goals, roles, and procedures, as necessary, for effective teamwork. 

1. How do we start the day? 

2. Practice Guidelines and Documentation (Chief Complaint, Vital Signs, Medical and Social History, Demographics, Allergies, and Medications) 

Provider 

MA/LVN/RN 

18 


Proactive Encounter Tools 

Administrative Tools 

‣Suggested Team with Roles and 

Responsibilities 

‣Proactive Care Readiness Check List 

‣Chart Review Tool 

‣Workflow Efficiency Audit Tool 

‣Physician Survey 

19 


Readiness 

Checklist 

20 


Physician 

Survey 

21 


Proactive Encounter Tools 

Training Tools 

‣POE Skills Inventory 

‣Skills Validation Tool 

‣Proactive Care CD & Web Site 

• Videos 

• Job Aids 

• All Administrative & Work Flow Tools 

22 


POE Skills 

Inventory 

23 


Skills 

Validation 

Tool 

24 


Proactive Care Tab 

Access to POE Checklists 

within HealthConnect 

screenshots

Proactive Care Activity Tab – Link to POE Checklists 

26 


POE Encounter Checklist Display 

27 


Proactive Pre-Encounter/Encounter Checklists 

Checklists will be 

generated for all 

patients identified 

as having gaps in 

care. 

28 


Proactive Encounter Pediatrics Checklist 

29 



• Dr. Morrells, Kaiser Permanente Physician 

and Member 

30 


Proactive Encounter 

SmartTools

Adult Proactive Encounter SmartSet 

32 


Adult Proactive Encounter Documentation 

SmartPhrase 

33 


Proactive Office Encounter 

Data

Proactive Encounter Tool Percent Utilization 

September 2008 

Target 75% utilization of POE Tools 

35 


SCAL Regional Trend: 

POE Composite Successful Opportunities 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Regional Successful Opportunities Report 

July 08 - August 09 

Percent Successful 

% A1c 

% Microalbumin 

% LDL 

% Mammo 

% Pap 

% Dexa 

% Pneumovax 

% Retinal screening 

% BMI 

% Flu 

% Smoking 

% Chlamydia 

% DM Health Ed 

% Asthma Quesr 

36 


Proactive Encounter in Urgent Care 

Bellflower Service Area Pilot Project 

November Successful 

Opportunity Rates 

•Pap Smear – 35% 

160 

140 

Pap Smears in Urgent Care 

July - November 2008 

150 

•Mammogram – 40% 

120 

120 

114 

•A1c – 32% 

•MAU – 15% 

Total Pap Smears 

100 

80 

60 

90 

94 

•LDL – 25% 

40 

•Chlamydia – 33% 

37 

20 

0 

Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 

Week 


Proactive Encounter in Surgical Urgent Care 

Bellflower Service Area Pilot Project 

(October – November 08) 

38 


Implementation Roadmap 

39 


Implementation Steps 

• Develop the leadership team 

• Assess readiness 

• Share the vision and workflows 

• Create department/condition specific work flows 

• Develop the training team 

• Train and validate skills 

• Measure performance 

• Performance improvement 

40 


Future: More Proactive Encounter work to 

continue through-out the year 

• In progress pilot of POE in Inpatient setting: Proactive 

Inpatient Encounter 

• In progress – Pilot analysis of Pre-Encounter 

automatic calls to members due for labs 

• Additional care gap alerts to be included in POE 

• POE in Emergency Department capturing labs 

• Automated Proactive Care Workflow Assessment 

• Automated Outreach for Overdue Labs 

• Development of POE in Pharmacy 

41 


Proactive Inpatient Encounter (PIE) 

Pre-Admission 

(ED/Pre-op) 

• Identify needed 

labs, screening, 

medication 

management, etc. 

• Provide member 

instructions 

Admission 

• Assessment, 

vitals, advance 

care directive 

documentation 

• Prepare patient 

for procedure, 

tests 

• Activate patient 

in care: education, 

nutritional consult, 

social service, 

discharge 

planning 

• Arrange DME, 

Home Health, 

Post Discharge 

Care 

Discharge 

• Identify and 

provide 

immunizations 

• Med reconciliation 

• Discharge care 

instructions, followup 

appointments, 

health ed materials 

• Screening 

reminders and 

appointments 

• KP.org registration 

• Post Discharge 

Call 

42 


Complete Care Experience 

43 


Success Factors 

- What practices and tools contributed to success? 

• Making it Personal 

• Regional pay for performance 

• Support the work: believe in it, implement it, reinforce it 

• Partner with your local POE Implementation Lead 

• Become familiar with elements of the POE model and workflow in 

Primary and Specialty Care 

• How to Document in HealthConnect TM (Chief Complaint, Vital 

Signs, Medical and Social History, Demographics, Allergies, and 

Medications) 

• How to use the POE Tool in POINT and POE Smartsets and Best 

Practice Alerts in HealthConnect TM 

• Understand how POE supports the physicians’ practice 

44 




• Create a Standard Workflow Agreement 

45 




• Physician direct involvement is critical to success of POE 

• Engage physicians or the MA will not see value and will not do it 

• Regional and local leadership support 

• Develop team agreements between your physicians and your nursing 

staff; this is a vital piece of the process 

• Implementation of Standard & Specialty Specific Workflows 

• Exam room readiness 

• Patient properly prepared for the examination 

• HealthConnect tasks pre-staged as appropriate 

• Better partnership between physician and healthcare team 

• Reward and recognize performance – “Nice Job” 

46 



• Mary Gonzales, Kaiser Permanente member 

47 


QUESTIONS / FEEDBACK

Contacts 

Kristen Andrews 

Proactive Care Group Lead 

Kristen.L.Andrews@kp.org 

Michael Kanter, MD 

Medical Director of Quality and Clinical Analysis 

Michael.H.Kanter@kp.org 

49

Proactive Encounter One Step Ahead

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