Primary Care at Kaiser Permanente:
Published in The Health Psychologist
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Roger Johnson, PhD, MBA, is a consultant who is working on projects associated with the Adult Primary Care (APC) service redesign at Kaiser Permanente of Sacramento, California. Central to this redesign is the implementation of an Integrated Primary Care (IPC) system. Dr. Johnson's work at Kaiser has centered on directing initiatives aimed at restructuring behavioral health services in order to provide evidence-based, protocol-driven interventions and improve service accessibility while furthering integration with primary care.
In a recent interview, Dr. Johnson stated that the purpose of the APC redesign is to "leverage" physician time by using Behavioral Medicine Specialists (usually psychologists), nurses, educators, and physician assistants. The intent is foster more efficient and effective medical care by ensuring that interventions match patient problems with the right professional and with the amount of expertise necessary to address the problem.
In this integrated primary care system, the BMS typically has 20-30 minute encounters with patients, often following a "warm handoff" from the patient's physician at the end of a regular primary care visit. Patients are seen an average of 2-3 times per treatment episode, conforming to what Nicholas Cummings has called "intermittent treatment across the life span." Focus groups conducted by Kaiser indicated that members experience greater overall satisfaction with this service redesign than with the older model of care.
According to Dr. Johnson, this integration of behavioral health and primary medical care requires a paradigm shift for most practitioners. Changing the setting where services take place implicitly results in a culture change affecting both patients and providers. In order to participate effectively, behavioral health professionals need to "speak the language (and with the diction) of medical doctors. " More specifically, BMS-types need to be practical, concrete, and succinct in interactions both with doctors and patients.
Dr. Johnson believes that the effectiveness of treatment is dependent on timely assessments regarding which type of intervention best fits the member. Kaiser is training both BMSs and physicians in using the Transtheoretical Stages of Change model to inform these intervention decisions. Working from such models, he believes, is key to psychologists being able to function effectively within the constraints of the primary care setting. Dr. Johnson stated "If you offer an intervention, but the patient isn't ready to make that kind of change, then the treatment will be ineffective. Matching patients with the right intervention (geared to their change stage) makes for greater patient satisfaction and a more efficient use of resources."
Psychoeducational classes conducted by the Behavioral Medicine Service are an important adjunct to the BMS role within the Kaiser integrated primary care system. Program content is designed to be consistent with the Stages of Change model. Currently, six different types of classes are available in the Kaiser Sacramento area. Foundational to the remaining classes is the introductory, "Pathways To Health", which focuses on helping patients understand the mind/body connection. More extended offerings include an eight-session mind/body education program for people prone to somatization, and an eight session chronic pain management program. Dr. Johnson reported that the overall effect of these classes has been to decrease medical office visits about 35%. This is based on comparing utilization for the six months prior, and six months subsequent to, initial Behavioral Medicine intervention.
In facilities where BMSs have been on the primary care units, member participation in Behavioral Medicine classes have experienced double the enrollment rate. A synergy is created by the combination of BMS contact and behavioral medicine programs. This has also created even more favorable responses in terms of increasing member completion of multisession classes and decreasing medical utilization, when compared with member referred by their physicians.
One of Kaiser's advantages in delivering this new model, Dr. Johnson stated, is their status as an integrated delivery system. "By being in charge of all aspects of care, Kaiser is able to implement programs where other systems can't: Specifically, the financial incentives are aligned, communication between providers is easier, and the information system (regarding medical utilization) is available to document the desired changes.
Dr. Johnson believes that three kinds of information are needed to build a business case for behavioral medicine interventions or an integrated primary care system. They are as follows:
1. Encounter data showing that these interventions reduce the cost of care;
2. Documentation of change in health status documentation to show treatment superiority;
3. Member satisfaction information indicating satisfaction with services.
Dr. Johnson noted that without such information, skeptics are not easily swayed. "Innovators are held to a higher standard of proof than those who are defending the status quo." Dr. Johnson pointed out that this information is often not readily accessible within an organization and often not available at all. Obtaining this information, though, is often a critical first step.
Overall, Dr. Johnson felt that integrated primary care is an exciting new paradigm. Despite its strong research basis though, and its intuitive appeal, it is not likely to be widely implemented until "early adapters" such as Kaiser have established the business case for such significant changes. "The paradigm shift has begun; the present challenge is for behavioral health professionals to capitalize on this opportunity to cost-effectively improve both the quality of life and health status of an aging population."
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Integrated Primary Care