Taking Action

Feature Story

ALL for Health

May 8, 2013



Kaiser Permanente extends new lifesaving protocol to community clinics

When it comes to diabetic patients at risk for heart attack and stroke, ALL says it all. A lifesaving protocol developed at Kaiser Permanente’s Care Management Institute, “ALL” stands for Aspirin, Lovastatin, and Lisinopril. Based upon Kaiser’s experience managing tens of thousands of diabetic patients, ALL has shown that when taken together once a day, this trio of low-cost, low-risk medicines reduces the chances of high risk patients developing a heart attack or stroke by more than 50 per cent.

Those numbers got the attention of Christy Rosenberg, director of the San Diego Council of Community Clinics Health Network. When she heard this news, she said, “Let’s jump on it,” and recruited Ken Morris, MD, the chief medical officer at North County Health Services and Jennifer Tuteur, MD, then medical director of Comprehensive Health Center.

Photo of Dr. TuteurDr. Tuteur, who helped roll out the protocol, oversaw the treatment of 800 diabetic patients at Comprehensive Health Center of San Diego County. Today, as associate medical director for quality at North County Health Services, she oversees the care of 1600 diabetic patients. More than 80 percent of these patients are uninsured, many are immigrants, some are homeless, and all are at risk of heart attack, stroke, and complications that can lead to blindness.

“Kaiser wanted to find out if their protocol would work in a community clinic and make a difference to our population of underserved people,” Dr. Tuteur says. “Could we contact indigent patients? Could we dispense the drugs effectively? Could we follow up a year later? Could we replicate the same results in a different system?”

ALL at work

Since the program began three years ago, 400 North County diabetic patients now participate, along with 100 patients at San Diego County’s Comprehensive Health Center and patients from two other clinics. The grant from Kaiser Permanente helps pay for data entry and maintenance of the disease registry, medications, and lab visits.

“We tell our patients, ‘This will save your lives,’” Dr. Tuteur says. “We believe that so strongly, you don’t even have to come to our clinics to get treatment. We can’t make a visit to a doctor a barrier to health.”

Each participating clinic implements ALL differently, with individual success, but each method works. One clinic mails patients their prescriptions and the medications they need, then follows up with a phone call. It’s an innovative approach nobody would have even tried if not for the example of Kaiser Permanente’s best practices, expertise, and experience.

Today 99 percent of patients are staying on the drugs and maintaining their health. “It’s a phenomenal record,” Dr. Tuteur states. For patient Guadalupe Rojas, the ALL protocol has literally been a lifesaver. “The ALL Program has helped me feel better,” Rojas says. “I’m healthier and it has helped me economically because the program services are free to me. I come every two months and get all of my prescriptions filled at the clinic as well.”

Not only has ALL reduced the risk of heart attack and stroke, but those enrolled in the ALL protocol are actually healthier than the patient population at North County Health Services. Dr. Tuteur explains, “We compared their comprehensive diabetic care, dental exams, cholesterol levels, blood pressure values, and self-management goals. Those enrolled in ALL scored better,
across the board, than our general patient population. ALL helps us manage the whole patient.”

Leveraging community support

“We’re not just looking at three meds,” Dr. Tuteur says. “There are other treatments these people need. For example, we have 300 diabetics in our study who are susceptible to blindness. We have the data we need to track them and identify those who are at risk.” To treat patients in the ALL protocol most at risk for blindness, Dr. Tuteur turned to the Scripps Whittier Institute for Diabetes, San Diego’s leading center for diabetes care, education, and research. “Once they saw our data,” she says, “they agreed to perform retinal scans at our clinic at no cost.”

Dr. Tuteur worked closely with doctors in the community to find surgeons who agreed to perform the laser surgery required to correct diabetic retinopathy. “We said, ‘We’ll only refer patients with retinopathy, and you can save their eyesight.’ We worked out low-cost, extended payment plans people can afford.”

ALL makes an impact

Dr. Tuteur has seen firsthand the impact of the ALL protocol. “We know ALL is reducing the risk of heart attack and strokes, and saving lives.”

What’s most exciting for Dr. Tuteur is that her patients “know there’s a community partner that cares about them enough to provide three drugs to prevent heart attacks and stokes. When a family member is in the room with them, the excitement is palpable. That really lights up their eyes.”


The ALL program has helped me feel better. I’m healthier and it has helped me economically because the program services are free to me. I come every two months and get all of my prescriptions filled at the clinic as well.

Guadalupe Rojas,
Patient