We have a forum. Quorum. Number 4, please. Approval with the possible modifications of the minutes set forth blow, regular Meeting Minutes from november 14, 2019. Action item. President breslin okay. Has everyone read the minutes . I have no corrections. I would like this comment, according to the minutes i talk too much. [laughter] so im going to try to be better. I keep you all here. Its terrible. But i have no corrections. Since he has no corrections, ill second the motion. President breslin all right. Any Public Comment on this item . Seeing none, all those in favor, aye . All those opposed. There are none opposed. Its unanimous. Item number 5. Item 5, general Public Comment on matters within the boards jurisdiction. This is a discussion item. Please come forward. Good afternoon, commissioners, my name is richard rothman, retired city worker. I thought after i retired i wouldnt have to come to these meetings, but i guess i do. I want to talk about the health fair. I went to the one at city hall and i found out that some of the vendors there had staff who could not answer questions. So i think when you ask the vendors to come, they should have staff who are familiar with our health plan and can answer questions. Because i think thats a good way to get answers, you know, through their bureaucracy. Although, i did go back to the health fair the last week down in h. S. S. Building there and found out from delta dental for the retirees that i think theyve been miscalculating the retirees dental benefits. That 1250 maximum should be excluded from the dental cleaning and they were if you reach the maximum, they were charging people for the dental cleaning, which was like my wife. And although it clearly says on the dental delta form on our web page that part is excluded. So theyre going to change it for my wife. And i think the staff needs to make sure that all other retirees get the same adjustment. That they dont have to pay for teeth cleaning and if they reach the maximum. And the smile program, too. Thank you for telling me about the smile program. But i found out that the dentist, when they look in the system, dont know youre in the smile system. So you might ask delta dental to look into that issue, too, thank you. President breslin any other Public Comment. Seeing none, item number 6. Item 6 is the president s report. This report is given by president breslin. President breslin i just want to question and bring up something that happened at the last meeting. It was the employees Assistance Program report when they were talking about First Responders. And knowing they need Specialized Service, but then, when i asked about for retirees, would they be included, and they said no, they could get their counseling through the system. And, of course, this group of people, the First Responders need Specialized Service for them to just go to the Mental Health program and get regular counseling would not be work very well. So i think and it said theyre going out for r. F. P. Does this r. F. P. Include retirees. The r. F. P. On behalf of five city agencies are deemed First Responders and it is not my understanding that it includes retirees, but we can investigate that. We are concerned about the Mental Health access for all members and active members do have access to employee Assistance Programs and there are specialized ones for First Responders. The question that you raised on whether there is Specialized Services for First Responders in retirement is a very good question. And were considering that. Weve been talking with all of our plans about Mental Health services and about specialization for First Responders. And so thats a conversation that is under way. And i think its something that is obviously worth investigating, because, probably, for sure people carry these issues into retirement. And hopefully, theyre able to transition their care, but as youll hear later in our report about member focus groups transitioning into retirement has a lot of legs, that whole issue, and well add to that. President breslin yeah, this is really important because it may get worse in retirement, maybe not better. Because in retirement, they have less to do and lack comradery testify at work, so it often gets worse. I think the suicide rate is the heightest in the Police Department in highest in the Police Department in the country. My limited understanding from talking with members of the Police Departments behavioral science unit, there is a gap. I think that conversation is very important to have going into retirement. At least the first five years of accumulated Mental Healthtype issues, exposure to things and that certainly does extend to all First Responders and likely other members of the Health Services themselves. Im happy to hear that is something that is being considered for retirees. Yeah, and i think as important is looking at ways to prevent the stresses from becoming a Mental Health issue for officers and other First Responders, our wellbeing program is working with various First Responder agencies to get in front of some of this. So i think thats as important as treating a condition once it occurs. President breslin so this, you think, will be in the r. F. P. , something to do with retirees . I dont think were waiting for the r. F. P. On this. Im sorry, the r. F. P. That the First Responders are doing, i cant speak to that at this moment. President breslin thank you, id like to hear a report back on that. Okay, i have nothing else to report. Is there any Public Comment on this item . This is item number 6. Seeing none, item number 7, please. Item 7 is directors report. This report is given by abbie yant, the executive director. Thank you, good afternoon, commissioners and i do, before i forget, want to wish everyone a happy Holiday Season and stay safe and dry. Kind of nice to have a wet season. So today a number of things that i spoke to in my strategic or my directors report will be spoken to further on the agenda. I do want to call out that we did provide an update on the progress that weve made in this first year of the strategic rolling out the strategic plan. Its been a very busy year and weve done a lot of discovery and investigation into all of the many the very long list of business initiatives that we overambitiously outlined in the report. And we have made progress on many of them. We are as a staff, were going to work intensively next week to really revisit those business initiatives and to be smart about what were going to focus on in 2020. And so were looking forward to doing that. The details are in the report and if there is any questions, we can speak to those today. We also just wanted to update, because i did get news about the sutter inn. We recently learned that the Class Action Lawsuit settlement terms are scheduled to be released on december 13th, thats tomorrow. Thats an original moveup from the original february date. We dont know if the settlement will have impact on h. S. S. , but well report back as we learn more about it. There are a number of followup items that ive addressed in this report. And one of them is working with blue shield and the brown medical group. Weve had a number of conversations with both the organizations and ive invited to the brown and tollen medical groups to come join us today. Can you call up their slides. Theyve prepared some slides that help explain the changes that are going on within brown and tollen. And im very appreciative they were able to be here today on rather short notice. And i think we heard the last time about the disruption we had during our open Enrollment Period because of these changes. And theyve offered explanation and status of the organization. Ryan, if you would go to the mic and introduce yourself . Thank you. Chief strategy officer. And Senior Vice President of network and business development. A couple of things that we were here to address, one is just to talk a little bit about changes at brown and tollen, kind of viability, stability, high level representation of kind of where the organization is going. Recognizing we make up a significant number of providers in the city. And the second, well speak about the evolution with sutter and the impact that has had. Apologize for the technical difficulties. There it is. There we go. So just to quickly summarize. Brown and tollen, been in existence for around 26 years. Weve represented and are included in seven bay area counties. We have ambitions to grow across 10 counties. We have 106 specialties represented. We have a network of over 2600 across the bay area. Approximately a little less than half of that is in the city or the west bay. And over the last year and a half or so, the organization has gone a transformation to really move the organization to one that is sustainable, diversifying products. And really expanding our product set. Several hmo products as well. Over the last year, weve renegotiated somewhere around 15 of our plans, both hmo and ppo. Weve started to really turn the organization around in terms of physician reimbursement, implementing a 10 improvement in physician reimbursement for those in our network this year. Another 7 next year. This plan, as well as addressing some of the specialist pay. Weve also been able to strike additional hospital contracts. And increase revenues by about 12 in 2019 from 2018. Increased our network size, number of physicians by over 25 . And then reduced our kind of business expenses, corporate expenses by over 25 as well. So really, you know, focused on turning around the business. These five pillars on this slide represent our key the key elements of our strategic plan. We are now in well, 2020 will represent the third year of that strategic plan. And obviously, moving to the next slide there, driving really transformation across all of these areas. Improving our Care Management capability, which is really wrapping around the physician, the kinds of healthrelated services that it really takes to provide good preventative and intervention care. Focusing on a new infrastructure, new technology in the organization, add on economical price for physicians to be able to survive and thrive. Were bringing on medicare products. We have overall eight plans . Eight plans total. Three new ones for 2020. Could i ask you to come to the microphone so this can be recorded and i can hear. So we have four new plans launched in 2020 for brown and tollen, so we are growing with all of our m. A. Plans with all of the national affairs. And you are. My name is teresa. We are in some ways lengthed with fetter and we have over the years developed a complicated set of contracts with fetter and we embarked upon an initiative this year to do a lot of cleanup of those contracts. And recognizing that sutter has its own competitive ambitions, as we do we. We recognize that in the city, there were 34 primary care fashions that were part of s. P. M. F. , that would be terminating. Its not really terminating, but their contract with brown and toland would be expiring at the end of the year. And we created reciprocity agreements so that sutter could access the brown and toland network and we could access their network. That number is 34. We have in place today, a reciprocity agreement that does achieve what ultimately our new agreement is interested in also achieving in terms of reciprocity around both specialist groups, but it is quite old and outdated and were interested in establishing something new as the current contract expires at the end of the year. Weve been in negotiations with them on this for better part of the year, nearly half the year or so. We have an m. O. U. , were hoping to execute that will bridge us into next year. We hope to have the reciprocity agreements in place by the end of january. So teresa will describe about the nature of the impact of these 34 physicians whose contract with brown and toland expires at the end of the year. I have a few slides. So complete what ryan was saying, late 2018, sutter, brown and toland began conversations with look at all of the agreements we have to reduce the administrative burden, to operationalize it, but this also included the physicians, hospitals, ancillary agreements and all agreements under sutter. So it was quite a large undertaking. Somewhere in the summer sutter communicated to us it was going to build their own network in San Francisco so began the conversations with terminating those pcps from the brown and toland network. We began conversations with them about the specialist as well as the pcps we started to have different conferences to minimize disruption with the membership. Through these conversations, sutter held strong they wanted to terminate the pcps but were open to the specialists. So we began looking at creating additional agreements that would support brown and toland specialists, sutter specialists, being able to see all of the members on either side. To solidarity date were to date, were continued those conversations and both sides want to complete this and support that access. Next line. As we look at the impact to this group, when we did this snapshot, we do hold reciprocity agreements. So to the member, it should seem seamless. We have the ability to refer and they have the ability to be seen by anyone from sutter as from a specialty care, or vice versa, if they need to see a brown and toland specialist. This is impact to us because we hold the risk for us, so it is a burden that brown and toland is bearing to make sure we have that access. Members assigned to nonsutter pcps should not see a disruption in care even if seeing specialists in the Sutter Foundation. It turns out we have 34pcps terminating from the network. Network add quays. Of those remaining, 2011 are open. We have opportunity and capacity to move anybody who wants to be moved. So we do have Contact Information from the brown and toland side from Member Services. Theyve all been trained and equipped to help navigate that and select a pcp that may be in their geography or based on their choices. President breslin am i hearing there are only 34 that may have a problem . 34pcps, our roster has 34 that we are early nating from the terminating from the brown and toland effective 2020. President breslin they will to anyone assigned to those 34pcps will have to look at either staying with those physicians or choosing a brown and toland doctor. President breslin so theyll have to choose a new doctor . Or they can stay with the sutter pcp . Does that put them outside the network, if they stay with a pcp that is not contracted by you. If they select a sutter pcp, it is a different network, and i think only one of your plans have that. They have access to brown and toland specialists through the reciprocity agreement. They dont have access to the brown and toland pcps, but theyll still see the cardiologist, et cetera. Have these folks been notified this is happening and how . What is being communicated. Paul brown from blue shield. We have two plans with you. We have trio and the access plus full network. The physicians that are leaving brown and toland and going to sutter are in the access plus network. They are not in the trio network. There are approximately 1500 members that are impacted by these physicians who are moving. About 1450 are in access plus, so they do not have to change their primary care physician. They can change their medical group to sutter and retain that pcp relationship. Or choose to stay with brown and toland and choose a new physician. There are 50 of your members in trio that would have to select a new primary care physician, because sutter is not in the trio network. The good news is this happened in open enrollment, so we did member notification on november 1st. Were required by the dmhc to give 60 days notice. So we released letters to all 1500 members explaining their options around november 1st. Right during open enrollment, or close to open enrollment, so if anybody wanted to change plans to align with their physician or medical group, they could do so during that open Enrollment Period. So really minimal disruption overall. But thats how we handled this from the health plan perspective. Background to say i was one of the original brown toland specialists. I think i still have my certificate of ownership of stock. So the question i have basically is, if someone who was one of the 49 or 50 shows up at the wrong office, they show up at office of somebody who now is no longer with brown toland, what will happen at the front desk . They do this february 1st. What will happen at the front desk . If this member has been assigned to a sutter pcp well, this member cannot be assigned to a pcp at trio if theyre a sutter member. So they will be assigned a new one. If they go to the sutter physician, the front desk should run eligibility and say you are not assigned to this particular doctor. So can you assure us that the mechanism is in place that we wont get angry phone calls for people who check in because even though i know theyve been informed and gotten letters, mistakes happen. Absolutely. Commissioner follansbee part of the problem i have, obviously, i was a physician for many years, but for members, patients, these medical groups are somewhat transparent. There is hill and this and that and there are all kinds of things, so people get very confused and may not fully appreciate. I guess the question is, can you assure us we wont be getting phone calls from the 49 who show up and is there a mechanism to deal with that . So the member should have a name on their membership card with an address to where to go. Commissioner follansbee right. That would be their primary care doctor. If they dont go to that location, the Sutter Foundation employee at the front desk and were not sutter should be running eligibility and explaining to them, because they dont control those, i cant assure theyre going to be able to say the right thing at the right time, but the card should indicate where they need to go. Best practice, when they make an appointment, that front desk should call and say youre no longer assigned to us, so they should be able to mitigate it from even coming in. Commissioner follansbee yeah agreed. But as you pointed out, this is very complex. And so i think that, again, appreciate these things happen, but i think we have responsibility to know that how things might be handled, mistakes happen. Mitchell griggs, chief operating officer. I wanted to tell the board with this question, we know who the 50 members are. And weve been researching. There has been band width with us perfecting all the enrollments and we have a list of the members and will work with them, if anyone is having problem after the first of the year. President breslin so when you say work with them, could they possibly go back to access to get the doctor they want . Yes. So some of them have for various reasons and probably because they did get this communication, and some of them have contacted us already. But we are also monitoring the others and reaching out to them as well that we have not heard from. President breslin thank you. I think the awkwardness, i mean it is a business practice that i think is difficult for many. The awkwardness for hss and members was the lack of any advanced warning. And you know, we got official notice from blue shield on november 1st at the close of open enrollment because they werent notified in advance. And i can understand when youre in that many contract negotiations, to be thinking about who is doing open enrollment when, but thats what made it very difficult for us, to have to reprocess these individuals and it makes us look bad. Like we didnt know what we were doing. And i think we did and it was alarming when members got the first notice we got of it, was from members who got letters from sutter. I got copies of this letter from sutter that went to our members without going through us. So it was, now e, weve down this road you know, weve been down this road before. I appreciate you coming here today to think through what happened and where were at today. And i just would appreciate you look at the impact of the contract negotiations to really think about these open enrollments, because its pretty traditional they happen in october or january around the world. So if we can be of some consideration, i think it would be most helpful to our membership. Absolutely. And do apologize for the miscommunication during open enrollment. It was our intent, we had started conversations with january to try to get ahead of this, and it was slow to respond once they notified us of building their own network. Commissioner follansbee one point and request for the future. One point, how does brown and toland update their open panel list of primary care . Is it updated every day . Every month . And how do members access that . So brown and toland update the health plans weekly with changes as in terms if a physician based on the policy qualifies to close their panel, then they notify us and we notify the health plan of that change within a week. So we send it out every week depending on when they send us notification. The lag would be about two weeks. And then the burden is on the health plans when they load it. We can also there is a phone number there for Member Services and that is updated realtime, so a member can call Member Services and we know realtime, if a physician is open or closed. Commissioner follansbee can we ask for maybe an update on this, maybe in february, how many if we identified 49 i believe, and how many of them either left and went to access plus and how many were successfully able to within a window find a new primary, so we have sense about the process for future . Because this will happen again. We know this. I think thats a great idea. I know its a constant juggle for everyone to know who is on what plan on what day of the week. I think the other thing, i would enjoy working with brown and toland and the other physician groups on, not just are they open to new patients, but are they truly available. Because thats especially when there is diminishing number of primary care, we are very interested in supporting primary care practices, because its the core. So wed love to continue to work with brown and toland and other groups on that matter. Happy to come back. President breslin thank you. Im going to defer anything else because we have a guest here from kaiser, so i want to respect the time. Ets up its up to the president , would it be okay to defer the Financial Report for the kaiser conference care . President breslin yes. Are you finished with the directors report . Yeah, im finished. I have one followup matter but we can take it later. President breslin okay. So were going to the item number 9 now. Right . Yes. Out of order, item 9, complex Care Management presentation presented by dawn ogawa. Hi, kate kesler, area Vice President for Kaiser Permanente. Wanted to thank you all for having us back to discuss complex Care Management. We have one of our physicians here. Ill let her introduce herself to you all. And dawn ogawa. Thank you so much for inviting me and to those in the audience as well. My name is dawn ogawa. Im an obgyn physician and the assistant chief overseeing health promotion. We wanted to continue the conversation we started in the last Board Meeting and based on questions about complex Care Management. So i wanted to start with the focus on the broader approach to managing the care of our members with more complex cases. And i wanted to touch briefly on how complex Care Management is core to what we do as an organization and how we have invested in tools to support this work, like the Electronic Medical record. Id also like to focus on the experience of our Kaiser Permanente members with more complex conditions in the outpatient and inpatient setting and what were able to achieve through this care. What can our members and Family Members expect if they have a complex or catastrophic condition . You see here on the next slide, a general overview. We placed the patient purposely in the center here with the support system around them. Our members have the benefit of awardwinning disease management programs that give them comprehensive range of integrated tools, resources, and services. So what makes Kaiser Permanentes approach different and successful . First of all, its proactive. We use Clinical Data drawn from our Electronic Medical record. The second and very importantly, its teambased and physicianled. Our physicianled care teams are individualized and assembled according to to the members care needs. The care is comprehensive. So we have a wide range of Preventive Care and selfmanagement tools to motivate members to effectively manage their conditions and to make that as easy as possible to do. Its also systemwide, because our industryleading electron medical record links every member, caregiver, hospital, physician office, pharmacy and lab in realtime, helping ensure accuracy and consistency of care. Its also data driven. Disease care registries help track outcome and determine effectiveness, enabling continuous improvement. Finally, and probably most importantly, its really patient centred. Members and care teams Work Together to determine the most appropriate clinical, social and educational interventions to meet their health goals. For example, i bring up the example of my patient who tested positive for diabetes in pregnancy. All of my patients get testing for this. If the patient has elevated blood sugar, shell be called right way by a specialized nurse who answers her question, and refers her to one of our dieticians. She has a number to call directly to a specialized nurse and i work closely with the nurse and the Patient Care Team to ensure her blood sugars are well controlled. This reduces her risk of complication related csections, low blood sugar for baby and making sure she is kept safe. My patient and her Health Care Team knows to recommend screening for diabetes yearly given the increased risk of this. Thats because its front and center in the Electronic Medical record. So we all know that lack of coordination can be a major barrier to providing safe care, particularly between the hospital and outpatient setting. At k. P. We focus on collaboration. This leads to better outcomes. K. P. Health connect is our leading Electronic Health record that identifies and eliminates gap in care while ensuring patient safety, every member, every time. All of the staff share this one medical record and the members care team can pull the entire medical history, labs, test results and prescriptions up. For example, going back to the prenatal patient with diabetes in pregnancy, shell now get reminders to do her diabetes screening along with Breast Cancer and Cervical Cancer screening when due. This eliminates care ga gaps and increases quality of care. So for our members with multichronic conditions who need complex care, k. P. s model is set up to reduce fragmentation. Were able to provide the right care at the right time. For example, i might see a patient in the office. I was seeing many this morning for abdominal pain or pelvic pain. When i see her, i can search her Health Record for emergency room visits. This improves parity safety by avoiding unnecessary testing. For example, a ct scan that would expose her to radiation that she might have had done a couple of weeks ago, or the overuse of antibiotics. In an Outpatient Care setting as a primary care doctor, were the quarterback for the members with complex care needs. We help them navigate through their care journey. Our Case Management is a focused high level care program for our sickest members with significant medical problems. That is there to assist the patients along with primary care doctors. Case management involves a process consisting of identifying high risk members, offering comprehensive assessments of their needs, providing assistance and setting treatment goals and coordinating care by a team of physicians and other health care professionals. You can see on the slide, all of the different people that are involved, whether its a dietician, a health coach, a health educator, you know, my medical assistant or program assistant. Members with chronic or catastrophic conditions are automatically enrolled in these programs and there is no sign up required, no homework they need to do. We want to make the right thing easy to do for members and families particularly when they have a chronic or catastrophic condition. Another key feature of our program, it isnt outsourced, so our physicians deliver and manage the care. We are the patients quarterback and best advocate. Im proud were able to do this quickly and compassionately because of our integration. I had a patient i diagnosed with uterine cancer and when i provided the results, i was able to hand off to oncology. She had an appointment within a day and her lifesaving surgery were quickly scheduled. Being able to provide this type of care is the reason i do my job, the reason i enjoy doing my job. Five years later, i continue to see her regularly for her followup and shes doing well. We also provide robust discharge support for patients. During the hospital stay, my hospitalbased physician colleagues partner with nurse patient care coordinators to develop a post discharge plan that leverages our integrated system. In this case, for patients who are hospitalized, it is the p. C. C. Who acts as the quarterback. They help navigate them through the care in the inpatient care setting. Closer to discharge, transition care pharmacists review medications with the patients. Additionally for complex patients at high risk of readmission, they follow up after discharge to ensure that theyre supported during the transition to home. Because of our comprehensive electron medical record, the entire outPatient Care Team, including myself, their primary care physician, specialists and disease specific care managers can view the entire course of treatment in the hospital. Im notified realtime if patients are admitted and discharged and what followup might be needed for them, all thanks to this integrated system. My team has access to discuss care and transitions. This is true for our patients discharged from both the hospital and the emergency room. In addition, all patients are provided clear written discharge instruction, including the 247 phone number to call. In our internal and contracted Home Health Agencies a Multidisciplinary Team provides care. Depending on the needs, nurses, social workers, therapists work to develop a care plan. We have nurse coordinators to provide oversight to them. The other area that we have the same system is our Skilled Nursing facilities. Skilled nursing facilities based p. C. C. S help with similar transitions to the outpatient setting. So Kaiser Permanente strives to reduce the rate of admissions in various ways. Effective discharge summaries and patient instructions, including postdischarge follow skraup and coordination followup and coordination with primary care. I know that was a lot of information about how we manage our care for our members with complex needs. But i think the proof is in the outcome. How does this impact members and what is their experience . I wanted to share this last these last two slides. This one is the performance for diabetes and Heart Disease management where we receive the highest level at five stars. Next slide. The result of the prevention and control has led to Kaiser Permanente outpacing the nation in reducing death from heart attack and strokes. If your Family Member is cared for at Kaiser Permanente, we know they have reduced risks of these outcomes. This is why Kaiser Permanente are focused on management and making sure members with complex needs are at the center of our approach to managing care. Id be happy to take questions. Commissioner follansbee i was a kaiser physician, so ive seen a lot of transition during my 16 years. I want to compliment you. The department of obstetrics and gynecology, their ability to track residents is one of the outstanding ones on the west coast. I would encourage you to include the education part as one of your one of our circles, because i think it really does. Absolutely. Commissioner follansbee a lot of what you referred to really does reinforce the impression about obgyn. A lot of your data in terms of Blood Pressure control and glucose is great, but the majority dont have complex conditions. Theyre being followed for one of two conditions and theyre ambulatory and certainly able to be monitored and engaged. So were looking at a narrower window. You mentioned home health care. From my standpoint, and i think i would suspect from our standpoint, is not a problem because it is totally integrated system. Usually the primary care provider transitions out. Yeah and they have a new primary care provider. Nd the system works because theyre homebound. Right. Commissioner follansbee it was a relief to me to see some of the patients transition to that because i knew they were getting superb care at that stage. Nursing homes i have to say was a bigger problem. Because most the Nursing Homes are not kaiser facilities, so what goes on, the primary care provider you refer to see the center of this, is completely out of the loop until somebody gets a discharge summary from so i guess of the questions, i have is could you focus on complex Care Management . We had a member stand up and say she and her husband were in the Emergency Rooms several times and never gotten a followup call from the emergency room. I know there is attempts to improve the liaisons, but i got the impression from earlier presentations there is an institutionalspecific and maybe dont translate across all kaiser facilities. And maybe departmentspecific. And i think that is kind of, from my standpoint, what were interested in. How that Smaller Group of people really get managed and handled. Ill just say one thing. That is when i joined kaiser in 98, the adult primary care model was rolling out. I think it was before your time. A little bit. Commissioner follansbee in medicine, we had a nurse on our module, we had behavioralist, all kinds of personnel in various stages of support and it was a team. And over the time of 16 years, i saw that nurse, we often used in a complex case for the department of medicine, transition out. And a lot of these nurses are now program not the same nurses, but if i developed Heart Failure, i have no doubt there is a Heart Failure nurse, but he or she is not necessarily dealing with kidney failure, hip fracture or my stroke and all that. So again, do you have information maybe on how those patients who are really complex and chronic get handled maybe outside the department of obgyn . Only what i shared with you in terms of primary care from the hospital. I think from the emergency room, the calls, those 24hour calls and pcps, thats are from discharges from the hospital setting in terms of the emergency room. You know, that i think its more the integration through the Electronic Medical record and the notification to the primary care doctor, to follow up with the pry imary care doctor. One of the opportunities for us is in the Geriatric Population and thats where we see a lot of, you know, the Management Opportunities for these more complex patients. Not just that one narrow specific disease for the whole person. Commissioner follansbee i guess i still hear a gap. And i think that we would be interested in hearing how that gap is being looked at. In terms of, i know as a specialist in the hospital, i would often say to the hospital and the house staff team, have you called the primary doctor . Do they know the patient is here and what is happening to them . A small fraction of them, i would bet, 5 of them make rounds in the hospital, on their own time to see their patients during hospitalization, by may be brief of longer. I understand the model, butt system but the system doesnt really encourage that and all of a sudden, the primary sort of gets handed a patient on discharge and sometimes the hospitals, they institute a program where the hospital called the patient a week later to see how theyre doing, but after that, the hospital was out of the picture. Assumption was the primary care, but they have, as in every health care system, not just kaiser, they have their hands fall just dealing with walkins that dont have insurance that day [laughter]. I want to make sure and i think this is your understanding, that the presentation wasnt about complex Care Management just in the obgyn setting. I know that, yeah. Its across all areas. I know in the discussions weve had in working on all of this, there has been a great deal of attention making sure that when members are discharged from the hospital, that there is that connection. So while i know that is not your area of specialty, we can certainly get somebody in here who can talk about that. I know in all of the prep work weve done that is a major focus. So maybe its a discussion about what has changed possibly. Because it is my understanding that is happening. Yeah, and the other thing i would say, we dont have to the apm model youre describing exactly, but we have brought back some elements of that. Over the past years weve worked to strengthen our medical assistant and physician partnerships. I was at lunch with three assistants who were talking about every day, every friday, they talk about their patients that theyre outreaching to. They share patient stories. The shared the story of a gentleman through their care team they were able to bring down his home globen from 1 down to 5. Not a nurse, but the m. A. Is also helping with the Care Management for the physician and weve brought Behavioral Health back into the primary care sort of team. This has been a focus over the past several years, making sure that is happening. But i didnt mean to say this was only for obgyn. Commissioner follansbee i understood that. I only hyded because i know that highlighted that because i know that department in San Francisco is the platinum standard for management of problems of any level of severity and complexity. I guess that, again, some of this is my prejudice from my own training, is that the nurse is the one in the complex chronic who can answer the phone, deal with any kind of problem, yes, you need to call an ambulance, yes, i can help you get in to see your kidney specialist, yes, i can help with the durable medical group. I will tell you, unless things have changed, the medical assistants, the behavioralist, all those people great at what they do, cant respond to the complex chronic patients urgent and semiurgent requests and i guess i would like to hear nursing that been reinvigorated into this role. Maybe im too vague. I appreciate that. I know we use nurses quite a bit in helping with that. I think that the fact is that the other piece of it is the email. For better or worse, that is an easy access point and a way for it to come through the primary care doctor and for the doctor to decide how to disseminate that and connect the patients with what they need. Whereas more traditionally, it was a call to a nurse. But what about members who dont have access to email . Commissioner follansbee im sorry. One more thing. Its a bugaboo. One is that i get a call, if im not picking up my most expensive medication from a pharmacist in their time frame. Because its so expensive. They want to make sure im adhering to it, i appreciate that. But all the other blood work asked for on a routine basis, because im not following a chronic condition, ive been ordered by my heart specialist, i get no reminders. I have no way to go into my medical record and find out what was due. And so i know that i had lab that was due at three months and i made the decision, because i remembered that, to wait six months, because i didnt think i needed it that often. So i went in when i thought i was ready. Thats great for me as a retired physician, but particularly for the chronic complex patient, the medical record doesnt support their selfmanagement. Gee, maybe its time you check out the peak flows. We havent seen documentation of that. See what im saying. I guess also i would say also we need to do a better job of advertising. My patients just joined k. P. Because they moved to california so im able to have proxy access, see when they refilled medication, see when theyre due for screenings. The app is one we did for just that. The my k. P. Meds app tells you when you refilled medications, when its coming due. Thats the other tool that we created to address that gap. I dont know if that commissioner follansbee it does. Just to point out that your list of manage the health care, misses i can see when the last hemoglobin was, but i cant see if i have one on order. And when that was due. And so thats what im trying to sort of bring in. That in order to get the results that you want, and want the member to be kind of in charge or his or her caretaker or spouse or whatever. It would be nice if there was a little more enhancement in that regard. Thats the only thing. That is good feedback and it is constantly being enhanced and changing. Absolutely, hopefully this will help to continue the discussion. I know there is still followup. And were happy to talk about complex Care Management as long as we need to. So director, we can follow up and see what other discussions we have, but im glad the doctor could come and share some of the information. Any other questions . Thank you. Thank you very much. President breslin is there any Public Comment on this item . Richard again, retiree. Ive been a kaiser member for more years than i care to remember. The kaiser doctors are great. I know two instances when a doctor came in on sunday night and operated and another instance, the doctor operated at 3 00 in the morning and saved the persons life. The integrated system is fine, but there is one flaw. Its the home health care. Kaiser contracts out with staffing nursing. And these staffing nurses are great, but they cant communicate with electronically with kaiser. They dont have access to kaisers date database. They cant send email to the doctor like a photo or send an email or communicate with the doctor. You know, either the kaiser patient has to do it or they have to send you know, do it over the telephone. And i think this is a serious flaw. You know, what upsets me is that kaiser wants to give a lot of money to the warriors and to the sharks, but they need to fix their infill system. Their doctors are great, but like this nursing issue. This really bothers me. Because its happening with my wife. And you know, the nurses are great, but they should be able to communicate with kaiser doctors. I dont see why cant they do that. And other things, about the shingles shot. Ive been waiting over a year and kaiser hasnt communicated. They said come in. Apparently now they have a weighting system, but why didnt they send out an email about it. I have to hear the only reason i heard about it, because my friends not in kaiser got them. So i started asking, you know, just by chance, my doctor told me to come when he got it to see him. And they didnt have any. Then i found out
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