SummaryTotal Panel Ownership, developed by Kaiser Permanente Hawaii and Kaiser Permanente Northwest, represents a population-based approach to care delivery in which self-governing teams of primary care providers develop and execute proactive plans to address gaps in care for a defined panel of patients during office visits and through followup services and outreach. Several information technology–based tools support the teams by highlighting discrepancies between recommended and actual care and providing timely feedback on performance. The program has increased adherence to evidence-based care and improved outcomes for patients with a variety of chronic conditions, enhanced continuity of care, and reduced reliance on resource-intensive office visits.Moderate: The evidence consists primarily of pre- and post-intervention comparisons of key measures of adherence to evidence-based care and patient outcomes.
Developing OrganizationsKaiser Permanente-Hawaii; Kaiser Permanente-Northwest
- Kaiser Permanente Hawaii Region and Kaiser Permanente Northwest Region developed the Total Panel Ownership program.
- Kaiser Permanente Information Technology from the Hawaii and Northwest Regions and the Care Management Institute's Population Care Information System workgroup developed the Patient Support Tool.
Date First Implemented2005
Vulnerable Populations > Medically or socially complex
Problem AddressedTypical methods of organizing the delivery of primary and preventive care services are associated with a number of problems that contribute to suboptimal care quality, inefficient care provision, and resource waste. These problems include:
- Reactive, rather than proactive, provision of care: Reactive (rather than proactive) care remains the norm, leading to higher costs and poorer outcomes; for example, one study found that HEDIS® (Healthcare Effectiveness Data and Information Set) measures were higher, and care costs were lower by up to $115 per member per month in an intervention group receiving population-based proactive care than in a comparison group receiving traditional care.1
- Gap between recommended evidence-based care and actual care provided: Many studies have shown that, despite the existence of evidence-based clinical practice guidelines, many patients do not receive recommended care.2
- Lack of a true team-based approach to care: Although many health care providers believe they take a "team approach" to care, the characteristics of real, cohesive teamwork are often missing, including striving to meet clear goals with measurable outcomes, leveraging clinical and administrative systems, working according to a division of labor, training all team members, and communicating effectively.3
- Limited physician resources that impede access to care: Physician shortages in many specialties and in certain geographic areas translate into delayed access to care for many patients; physician extenders such as nurse practitioners and physician assistants can help improve access, but appropriate delegation of care to these clinicians is often lacking.
- Limited options for care: Face-to-face, office-based care is the traditional care option; yet, other seldom used options, such as telephone and e-mail consultations, could facilitate access, leverage physician time, and enhance patient satisfaction.4,5
- Reluctance to pursue novel care processes: Many organizations do not actively encourage clinicians to pursue new care processes; as a result, barriers, such as limited clinician time and fear of failure, often prevent clinicians from designing new systems of care.
Description of the Innovative ActivityTotal Panel Ownership represents a population-based approach to care in which self-governing teams of primary care providers develop and execute proactive plans to address gaps in care for a defined panel of patients during office visits and through followup services and outreach. Several information technology–based tools support the teams by highlighting discrepancies between recommended and actual care and providing timely feedback on performance. Key elements are described below:
- Core teams overseeing panel of patients: Panels of patients are overseen by the "core team," which typically consists of a primary care physician (PCP) supported by a full-time medical assistant, registered nurse (shared across teams), nurse practitioner (shared), and receptionist (shared). Each core team oversees a panel of approximately 2,000 patients. (Members can choose their own PCP, but those who do not are assigned to one.)
- Flexible access options: Although face-to-face visits remain a mainstay of care, patients are given a wide array of other options for accessing and communicating with providers, including phone consultations, e-mail consultations, self-care, and group appointments. Although reliance on such options varies, office visits in some clinics now represent less than one-half of total clinical activity.
- Technology to identify gaps in care: The core team uses the Panel Support Tool, a computer program that highlights for each patient the gaps between optimal care as recommended by evidence-based guidelines and the care actually provided. Approximately 25 evidence-based measures are incorporated into the tool; examples of measures include annual eye and foot examinations for diabetes patients, aspirin use for patients with coronary artery disease, blood pressure medication for patients with various chronic diseases, and osteoporosis medication for women age 65 years and older with low bone mass density. This tool was recently expanded to incorporate pediatric care, covering immunizations, well-child examinations, management of obesity, pediatric asthma, attention deficit hyperactivity disorder, and juvenile diabetes.
- Proactive care for individual patients to fill gaps: Before a patient visit, the medical assistant calls up the patient's screen in the tool, which highlights care gaps in red; the medical assistant then sets up physician orders for followup care. During the visit, the physician addresses the patient's presenting problem and then discusses gaps in care across a spectrum of conditions. The physician signs the orders for followup testing and services, as needed, to address the care caps. The team also works to ensure seamless transitions to and from any needed specialty care.
- Periodic team meetings to plan proactive care and outreach: At regular meetings, the team reviews current care needs of the panel and individual patients. Core teams are encouraged to identify each patient's care needs proactively and individualize care accordingly, such as by having an annual "touch" with each panel member, providing disease management to patients with chronic conditions, and offering general education on healthy lifestyles to younger, healthier members.
- Support team to conduct outreach: A group called Panel Support Services, staffed by a mix of clinical pharmacists, nurse practitioners, and medical assistants, provides support to the teams, focusing primarily on hyperlipidemia and hypertension in high-risk cardiovascular patients and secondarily on diabetes and primary hypertension. Organized into teams responsible for PCP panels within a geographic area, the support teams proactively reach out to targeted, at-risk individuals through group classes and phone calls. Support service staff round at least monthly with their assigned PCPs to review progress, select patients to target, and strategize about appropriate interventions. Future plans call for expansion of this service to new diagnoses (e.g., congestive heart failure, asthma, osteoporosis), populations (e.g., frail elderly), staff, and workflow applications.
- Population-based care management and performance feedback: As of early 2009, a comprehensive performance feedback and intervention tool known as "How Are We Doing?" had been deployed to all PCPs in the region. Linked to the electronic medical record (EMR), this interactive tool presents PCP panel-specific performance data on quality (e.g., access and visit satisfaction, clinical processes, and intermediate outcomes) and resource stewardship/costs (e.g., formulary compliance, referral rates by topic, use of imaging procedures). The tool can report data at the level of an individual patient, PCP, clinic, specialty, or region and is linked to continuing medical education content specific to the clinical processes being highlighted.
- "Culture-of-excellence" rounding: All supervising staff make monthly patient rounds using a standardized format focused on quality. In some cases, this step is augmented with a review of performance data from the "How Are We Doing?" tool described above.
- Encouraging an entrepreneurial spirit: Teams are encouraged to try new experiments in care via the 21st Century Care Innovation Project, a national Kaiser project to use Kaiser's EMR to deliver care in different ways. Through that project, the core teams use a rapid-cycle Plan-Do-Study-Act approach to test new ideas, with the goal of spreading them throughout the region. New experiments that have resulted in positive improvements include allowing the patients to see their own doctor; addressing same-day demand; and having the medical assistant use the Panel Support Tool to close care gaps.
References/Related ArticlesVogt TM, Feldstein AC, Aickin M, et al. Electronic medical records and prevention quality: the prevention index. Am J Prev Med. 2007;33(4):291-6. [PubMed]
Livaudais G, Unitan R, Post J. Total Panel Ownership and the Panel Support Tool—"It's all about the relationship." The Permanente Journal. 2006;10(2):72-9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076975/.
Roblin D, Vogt TM, Fireman B. Primary health care teams. Opportunities and challenges in evaluation of service delivery innovations. J Ambul Care Manage. 2003;26(1):22-35. [PubMed]
Contact the InnovatorSamir Patel, MD
Kaiser Permanente, Hawaii
87-2116 Farrington Hwy
Waianae, HI 96792
Phone: (808) 432-3549
Innovator DisclosuresDr. Patel reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.
ResultsThe program has increased adherence to evidence-based care and improved outcomes for patients with a variety of chronic conditions, enhanced continuity of care, and reduced reliance on resource-intensive office visits.
Moderate: The evidence consists primarily of pre- and post-intervention comparisons of key measures of adherence to evidence-based care and patient outcomes.
- Greater adherence to evidence-based care: Several indicators suggest the program has led to increased adherence to recommended care, with small but meaningful increases achieved in the appropriate use of the following between January 2006 and April 2011:
- Statin therapy: from 67.8 to 78 percent
- Angiotensin-converting enzyme (ACE) inhibitors: from 61.9 to 69 percent
- Beta blocker after myocardial infarction: from 78.9 to 80.5 percent
- ACE inhibitor for heart failure: from 71.1 to 75.1 percent
- Beta blocker for heart failure: from 69.6 to 76 percent
- Aspirin in high-risk populations: from 53.5 to 75.1 percent
- Annual blood glucose screening in diabetic populations: from 85.3 to 94 percent
- Annual renal screening/therapy in diabetic populations: from 82.7 to 88 percent
- Annual low-density lipoprotein (LDL) screening in cardiovascular disease and diabetic populations: from 81.3 to 90 percent
- Mammography: from 67 to 76 percent
- Colorectal cancer screening: from 30.5 to 61 percent
- Cervical cancer screening: from 68 to 73 percent
- Cholesterol screening: from 70 to 73 percent
- Pneumococcal vaccinations: No change at 86 percent
- Improved outcomes: Between February 2008 and April 2011, the percentage of targeted patients who have achieved established therapeutic goals has increased in a number of areas, as outlined below:
- LDL levels below 100 for patients with cardiovascular disease and diabetes: from 57 to 71 percent
- Blood pressure below 139/89 for patients with cardiovascular disease and diabetes: from 64 to 87 percent
- Blood pressure below 139/89 for those with primary hypertension: from 72 to 90 percent
- Hemoglobin A1c below 7.0 for those with diabetes: from 32 to 42 percent
- Less reliance on resource-intensive clinic visits: In the region, 30 percent of patient encounters now occur by phone, compared with just 10 percent before the program was implemented.
- Greater continuity in patient–provider relationships: The percentage of patients seeing their own PCP (assuming the PCP was working on the day of visit) increased from 73 percent to 97 percent.
- Additional anecdotal benefits: The following anecdotal benefits have been reported by those who have used this program6:
- Avoidance of expensive acute care through use of phone triage and early intervention
- Elimination of costly waste via less rework
- More effective use of staff time, as medical assistants meet some care needs
- Higher member retention owing to greater patient familiarity with particular providers and more patient touches
- Higher staff retention, as staff feel more ownership over patient care
- Greater involvement of staff in managing costs, as they actively promote alternative forms of patient–provider contact (e.g., group visits, phone calls, e-mail) because they better understand their potential benefits
Context of the InnovationKaiser Permanente, the largest nonprofit health plan in the United States, is an integrated health care delivery system serving 8.9 million members in nine states and the District of Columbia. A handful of physicians in the Kaiser Hawaii region (serving 220,000 patients) and the Kaiser Northwest region (serving 450,000 patients) expressed interest in developing better, population-based care management strategies, in particular by leveraging the use of Kaiser's EMR and by developing new technological care management tools.
Planning and Development ProcessThe Total Panel Ownership strategy and the Panel Support Tool were developed based on a series of site visits and internal meetings, in conjunction with a structured technology development and rollout process. Key steps were as follows:
- Site visits and conference participation: Physician leaders from Kaiser Hawaii and Kaiser Northwest traveled to other Kaiser regions to gain ideas for how to improve population-based care. Physicians also attended an Institute for Healthcare Improvement conference to gain insight into quality improvement ideas and techniques.
- Strategy development: The physicians decided to enhance population-based care by focusing on identifying and addressing gaps in care. Keeping other regions' activities in mind but wanting to develop strategies specific to their own patients' needs, these physician leaders decided to focus on use of physician-led teams of clinicians who take ownership over a panel of patients.
- Identification of evidence-based measures to be tracked: Calling on the expertise of different Kaiser specialists through a survey, the physicians compiled a list of evidence-based measures for major diseases and for crucial components of preventive care.
- Panel Support Tool development, testing, training, and rollout: Working with input from the physician leaders, Kaiser information technology staff developed the Panel Support Tool, which links the evidence-based measures to Kaiser's EMR, highlighting gaps in care for individual patients and analyzing performance across panels of patients and care teams. The tool was built and pilot tested at a few small sites in the Hawaii (late 2005) and Northwest regions (early 2006). Developing physicians then met with different teams to discuss the Total Panel Ownership concept, describe the new work process, and train staff members to use the tool, which was implemented region-wide in 2006. Kaiser later developed the pediatric version of the tool, implemented in 2008.
Resources Used and Skills Needed
- Staffing: This initiative required high-level physicians to investigate and develop the new process and provide input into the Panel Support Tool. As noted, information technology staff built the tool.
- Costs: Development costs are not available. Costs will likely vary significantly depending on an organization's culture and existing information systems.
Funding SourcesKaiser Permanente-Hawaii; Kaiser Permanente-Northwest
Kaiser Permanente Hawaii Region and Kaiser Permanente Northwest Region provided the bulk of funding for development of the program. Kaiser's national 21st Century Innovation Project (described earlier) provided a small grant to develop and host the online linkages to continuing medical education materials.
Getting Started with This Innovation
- Encourage new approach to care: Educate caregivers on the benefits of adopting a new mentality and approach to patient care that expands the focus beyond a patient's presenting complaints to all preventive and care management needs and beyond managing the care of an individual patient to managing an entire panel of patients.
- Allocate responsibilities across team: Make sure that team members understand their roles and responsibilities, with the right person providing appropriate services to the patient.
- Consider alternatives for accessing care, communications: In certain circumstances, education and other services can be effectively and efficiently delivered by phone or e-mail.
Sustaining This Innovation
- Continue communication, outreach: Such efforts must be ongoing to sustain improvements.
- Monitor and report on performance: Continually review each team's performance to ensure that new gaps in care are being proactively identified and addressed.
Wise CG, Bahl V, Mitchell R, et al. Population-based medical and disease management: an evaluation of cost and quality. Dis Manag. 2006;9(1):45-55. [PubMed]
Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458-65. [PubMed]
Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246-51. [PubMed]
Wasson J, Gaudette C, Whaley F, et al. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267(13):1788-93. [PubMed]
Stone JH. Communication between physicians and patients in the era of E-medicine. N Engl J Med. 2007;356(24):2451-4. [PubMed]
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Service Delivery Innovation Profile
Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 08, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.