Kaiser Permanente Chronic Care Management Initiative


Under the BCCQ Program, the experts of IHQC first began work in the Sacramento region in 2014. We partnered with Kaiser Permanente Northern California Community Benefit to assess the readiness and capacity of local community health centers to implement and sustain a quality improvement initiative linked to regulatory reporting requirements and evidence-based health care delivery approaches. The findings from this readiness assessment were used to inform a learning community for these clinic organizations where IHQC staff led trainings on the fundamentals of QI and provided coaching and technical assistance around completing a short-term improvement project.

Building on these efforts, IHQC is again partnering with Kaiser Permanente Northern California Community Benefit to launch a year-long learning collaborative with the Sacramento community clinics to expand their capacities around population health management. This initiative is a part of Kaiser Permanente’s larger Preventing Heart Attacks and Strokes Everyday (PHASE) Initiative. Implementing comprehensive population management programs like PHASE can be a complex undertaking and requires coordinated efforts of staff from across an organization. This often requires leadership to support these large-scale efforts by rolling out evidence-based protocols, having proactive and planned interactions from providers and staff operating in a team-based care environment, offering effective health education and self-management support, implementing patient follow-up and outreach, and optimizing IT systems and data reports. Leveraging our experience in leading the BCCQ Program and partnering with other industry experts, IHQC will lead a quality and process improvement training program tailored specifically to assist these Sacramento clinics as they implement projects that improve the care provided to patient populations and build their capacity for comprehensive care management.

Case Study

In their initial improvement projects, the Sacramento teams used multiple tools and approaches to improve their clinical operations, including workflow maps, fishbone/cause and effect diagrams, checklists, data collection worksheets, communication plans, improved team huddles, and staff trainings. Through these efforts, teams saw improvements in a number of project measures, including:

  • Improving % of pain management patients with BP under control from 23% to 75%.
  • Decreasing cycle time from 90 minutes to 45 minutes.
  • Increasing the % of children with up to date immunizations from 60% to 74%.

Moving forward, the Sacramento teams have scoped population health management projects focusing on either diabetes, hypertension, or cervical cancer screening rates. IHQC will be leading workshops and providing technical assistance and consulting support to clinics as they implement these projects and build their staff improvement skills, health education programs, and optimize internal processes and procedures.

  • If you are a participant in the Sacramento Initiative, log in using your cohort username and password to get access to presentations, tools and other resources. For more information about the Sacramento initiative, Contact Us.

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