OAKLAND, California — Kaiser Permanente is providing $5.25 million in grants to launch a new, two-year effort that will increase access to care for patients who are at risk for heart attacks and strokes. The investment supports 17 community organizations across Northern California that will work together to expand the reach and scope of Kaiser Permanente’s Preventing Heart Attacks and Strokes Everyday program, known as PHASE.
PHASE combines three medications, along with lifestyle changes, to provide a cost-effective treatment for people with existing heart disease and those at greatest risk for developing it, including diabetics age 55 years and older. By providing a single-pill, fixed-dose treatment, the heart healthy regimen has helped Kaiser Permanente Northern California reduce heart attacks and stroke-related hospital admissions among its own members by 60 percent.
“Before PHASE, treating people with heart disease could require many office visits and phone calls — as the patient and physician worked together to find the right combination of medications and behavior modifications,” said Marc Jaffe, MD, endocrinologist and internist at Kaiser Permanente South San Francisco. “This made it difficult for some members to stick with their treatment plan. We developed the PHASE program in 2002 with the goal of reducing heart attacks and strokes by making treatment more accessible, affordable, consistent and convenient for our members.”
In 2006 the organization began sharing the program with community health centers through a combination of grant funding, clinical expertise and physician mentors. Today more than 50 clinic sites in Northern California are participating in PHASE and serving more than 35,000 people enrolled in the program.
According to Ralph Silber, executive director of the Alameda Health Consortium and chief executive officer of the Community Health Center Network, implementing PHASE in 2007was also the catalyst for other changes.
“The PHASE grants from Kaiser Permanente helped us make significant enhancements in technology and work processes,” said Silber. “We had to make these changes in order to implement PHASE, a tremendous added benefit was that it also helped us be better prepared to respond to new federal reform requirements.”
Eight of the new grants will continue support for health organizations that are already using PHASE, to help them increase enrollment and expand the program’s scope to treat other conditions, such as hypertension. The other grants will help six additional health organizations adopt team-based care models and technical improvements — such as electronic health records — that are foundational for implementing chronic care programs, including PHASE. Three grants will support overall evaluation and training support for the overall initiative and PHASE grantees. The $5.25 million contribution was reviewed and approved by the Kaiser Permanente Board of Directors Community Benefit Committee, chaired by Cynthia Telles, PhD.
“Collaboration saves lives, and it is helping us participate in the transformation of care delivery,” said Dr. Jaffe. “By taking the best of what’s working for our members and sharing it with the larger health care community, we are also beginning to develop a more efficient care delivery model that results in better health.”
PHASE grants will be paid over the next two years. Recipients include:
- Alameda Health System received a $400,000 grant to continue and expand its existing PHASE work, and expects to increase the number of patients enrolled by 30 percent. They will also increase data collection, engage patients in health education and expand its team-based approach to care.
- Building Clinic Capacity for Quality/Community Partners received a $400,000 grant to conduct ongoing needs assessments among community health providers and to coordinate peer group training in process improvement learning opportunities.
- CARES Community Health received a $125,000 grant to improve their data collection capacity and work processes, and focus on improving health outcomes among African Americans with hypertension and Hispanics with diabetes.
- Center for Care Innovations received a $600,000 grant to support community health organizations that are implementing PHASE by developing tools for measuring effectiveness, providing on-going data analysis, and creating forums to share and spread best practices among all PHASE participants.
- Center for Excellence in Primary Care (University of California, San Francisco) received a $250,000 grant to assist with evaluation and metrics, and will develop an interactive training curriculum for community health organizations that are implementing PHASE.
- Chapa-De Indian Health Program received a $125,000 grant to help provide training for their staff, evaluate care team designs and test models for increasing use of patient data.
- Community Health Center Network received a $400,000 grant to expand PHASE among its clinics’ patients and increase its scope to include hypertension treatment. The Network’s member clinics will also work to further develop their patient electronic health records to support enhanced data collection.
- Community Health Partnership of Santa Clara received a $400,000 grant to increase enrollment in its PHASE program by 30 percent, and expand it to treat other chronic health conditions. It will also develop a coordinated care approach and a data analytics tool to be used by all of its member organizations.
- Elica Health Centers received a $125,000 grant to focus on integrating primary care, preventive care, chronic disease management and behavioral health services to use patient electronic health records and team-based care.
- Redwood Health Coalition received a $400,000 grant to continue and expand PHASE to an additional 40 percent of their patients. It will also focus on enhancements to its data analysis systems, hypertension treatment and training for health care providers.
- Sacramento Native American Health Centers received a $125,000 grant to focus on improving their specialty care referral systems, and to refine policies and practices for care coordination.
- San Mateo Medical Centers received a $400,000 grant to continue and expand the reach of their PHASE program, anticipating an enrollment increase of 40 percent. They will also increase data collection and analysis, and train staff to become health coaches who engage patients in lifestyle change.
- San Francisco Community Clinic Consortium received a $400,000 grant to continue PHASE and expects to increase the number of patients enrolled by 50 percent. It will also focus on staff training for its member clinics and incorporating hypertension treatment and patient registry/panel management tools.
- San Francisco General received a $400,000 grant to expand its PHASE program, and is expecting to reach an additional 40 percent of patients. The organization will also focus on optimizing electronic data collection, lifestyle interventions and develop a team-based approach for chronic care management.
- Santa Clara Valley Health & Hospital Systems received a $400,000 grant to continue its PHASE program and increase enrollment by 30 percent. It will also focus on staff training, increased data collection and lifestyle and behavioral interventions to treat hypertension.
- WellSpace Health Centers received a grant for $125,000 to develop team-based care models and implement patient tracking and analysis tools.
- Winters Health Centers received a $125,000 grant to build their team-based approach to patient care and will provide training for staff to develop their ability to engage diabetic patients with self-management tools.
About Cynthia Telles, PhD
Cynthia A. Telles, PhD, has served on the boards of Kaiser Foundation Hospitals and Kaiser Foundation Health Plan, Inc. since April 2003. She serves as chair of the Community Benefit Committee and also is a member of the Audit and Compliance Committee and Executive Committee, and serves on the Executive Advisory Board of Kaiser Foundation Health Plan of Georgia, Inc. Learn more about Cynthia Telles on her website.
About Kaiser Permanente
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve approximately 9.5 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: kp.org/share.