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OBJECTIVE To understand factors leading to all-cause 30-day readmissions in a community hospital population. RESEARCH DESIGN Structured case series of 537 readmissions using chart reviews, interviews with treating physicians, patients and family caregivers, and overall case assessment by a nurse-physician team. SETTING Eighteen Kaiser Permanente(More)
We examined the patient activation measure's (PAM's) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence, compared to patients with the lowest PAM scores. This(More)
The Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral and quality measures for patients with chronic conditions. To examine the relationship between PACIC(More)
BACKGROUND Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. (More)
BACKGROUND Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern(More)
CONTEXT Panel management is an innovative approach for population care that is tightly linked with primary care. This approach, which is spreading rapidly across Kaiser Permanente, represents an important shift in population-care structure and emphasis, but its potential and implications have not been previously studied. OBJECTIVE To inform the ongoing(More)
BACKGROUND Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is(More)
BACKGROUND Identification of potentially preventable readmissions is typically accomplished through manual review or automated classification. Little is known about the concordance of these methods. METHODS We manually reviewed 459 30-day, all-cause readmissions at 18 Kaiser Permanente Northern California hospitals, determining potential preventability(More)
BACKGROUND In 2004 Kaiser Permanente Southern California (KPSC) recognized the potential to improve the quality of care. Healthcare Effectiveness Data and Information Set (HEDIS) performance was below what regional leadership aspired to achieve, exceeding the 90th national percentile on only 15 of 34 measures. Beginning in 2005 regional leadership(More)
OBJECTIVE To assess the effect of promoting a bundle of fixed doses of a generic statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), delivered with minimal outpatient visits, laboratory testing, and dosage titration, to people with diabetes, coronary artery disease (CAD), or both in a large integrated healthcare(More)