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‘Complete Care’ Approach Improves Patient Outcomes

Kaiser Permanente reports positive results with chronic-care management model (October 23)

Complete Care, a collaborative approach to meeting patient needs, is improving outcomes for Kaiser Permanente patients, according to a report in the November 2013 issue of the Joint Commission Journal on Quality and Patient Safety.

The design of Complete Care is based on a chronic care model that originated 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.

The new approach has helped Kaiser Permanente create rare disease programs for patients with Down syndrome, spinal cord injuries, and amyotrophic lateral sclerosis (Lou Gehrig’s disease) and allows the management of most conditions seen in an outpatient setting, according to the report. It works in conjunction with care-management programs that promote exercise and obesity management, and that screen for aortic aneurysms and alcohol overuse.

A key feature of Complete Care is the practice of “proactive office encounters.” This approach 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. According to the report, bringing the entire care team into this process has improved the consistency of preventive care, the quality of chronic-conditions care, and the reliability of staff support for physicians. It also motivates staff to respond while they have the attention of a receptive patient.

“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,” said lead author Michael Kanter, MD.

Source: Kaiser Permanente; October 23, 2013.

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