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 obgynhe 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