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Urgent message: As the Affordable Care Act encourages greater integration of health insurers, hospitals, and physicians, urgent care will play an important role in increasing patient access, improving clinical outcomes and reducing health care costs.

ALAN A. AYERS, MBA, MAcc, Experity

Hospitals across the country are partnering with doctors and health insurers—linked by an electronic health record (EHR)—to form accountable care organizations (ACOs) as a way to control health care expenditures by coordinating patient care. This model of care, supported by the Affordable Care Act, has been pioneered and refined by systems such as Intermountain Healthcare in Utah, Geisinger Health System in Pennsylvania, Henry Ford Health System in Michigan, and Oakland, California-based Kaiser Permanente.

In this exclusive question-and-answer session with JUCM – The Journal of Urgent Care Medicine, Michael A. Neri, Jr., MD, and Peter A. King, MD, detail the operating models, capabilities and connectivity of urgent care in the nation’s largest managed care organization with over 9.5 million members, 17,000 physicians, 174,000 employees, and 650 hospitals, medical offices, and outpatient facilities in eight states and the District of Columbia.

Dr. Neri is Regional Physician-In-Charge of Urgent Care and Riverside Area Assistant Medical Director for Kaiser Permanente Southern California and Dr. King is Physician Director of Acute Care Services for Kaiser Permanente Georgia.

Alan Ayers: What does urgent care look like within Kaiser Permanente today including locations, hours, clinical capabilities and staffing models?

Michael Neri: At Kaiser Permanente, our urgent care model differs depending on local needs and whether we own and operate hospitals in the area. Therefore, to provide a comprehensive overview of Kaiser Permanente’s approach to urgent care, my colleague Dr. Peter King and I will discuss how we provide urgent care in Kaiser Permanente Southern California and Kaiser Permanente Georgia. No matter where our members receive care, our urgent care centers are staffed by highly skilled Kaiser Permanente doctors and nurses. Our primary goal is to provide members with convenient access to high-quality, coordinated care.

Kaiser Permanente Southern California has 19 urgent care locations throughout the region that offer walk-in access in the morning, afternoon, and evening, 7 days a week. All of our urgent care locations operate at a higher capability than the typical community cold and flu “urgent care” model. We are able to provide care to patients with mild-to-moderate acuity ailments, including medical and surgical issues. The benefit of a higher-acuity urgent care center is member convenience and access, because members do not need to be transferred to the emergency department for workup.

Peter King: Kaiser Permanente Georgia uses a model that we call Advanced Care Center (ACC). An ACC is an outpatient facility that is physically located in a Comprehensive Medical Center (a medical office with full services including high-tech radiology, cardiac stress testing, and a gastrointestinal (GI) endoscopy suite). The ACC offers high-acuity immediate care and is staffed with board-certified emergency physicians and emergency room (ER)-trained nurses. Although the ACC is designed to provide urgent care, in the event of a higher-acuity emergency, this facility is prepared and is similar to a hospital ER. The ACC has an on-site pharmacy with intravenous (IV) medications commonly used in an ER, such as equipment for central IV lines, cardiac monitors, and respiratory support. Our ACCs are open 24 hours a day, 365 days a year.

Alan Ayers: What is the role of urgent care in increasing access to and reducing medical costs within Kaiser Permanente’s integrated model of care?

Michael Neri: Urgent care provides our members with another option when they need care quickly. It plays a key role in providing care for members who require prompt medical attention conveniently, but who do not have an emergency medical condition. This care is delivered with the same high quality and service as in our Emergency Department, but at a lower cost to our members.

Peter King: Our ACCs are a prime driver of increased access and decreased cost for our members with acute medical needs who do not require ER care. With ACCs, we can treat patients in the outpatient setting, which is often more convenient and effective for patients. For example, we are able to evaluate, treat, and discharge many patients with transient ischemic attack, atrial fibrillation, chest pain, GI bleeding and numerous other conditions. We routinely evaluate patients with chest pain, ruling out acute heart attack, observing overnight, and obtaining stress testing the next morning. We are able to rapidly stabilize and transfer patients who need hospitalization. 

Alan Ayers: How does Kaiser Permanente ensure or coordinate follow-up with a primary care or specialist after a patient presents for urgent care with a new medical diagnosis? What is the role of Kaiser Permanente’s consolidated medical record in ensuring continuity of care?

Michael Neri: Kaiser Permanente’s comprehensive EHR, KP HealthConnect, is essential in ensuring continuity of care. Every primary care and specialty care provider has immediate access to any patient encounter in urgent care. We have standardized protocols to ensure that patients are connected to primary care or specialty care follow-up as needed.

Alan Ayers: How does Kaiser educate its members about the availability and appropriate use of urgent care services? Is there any incentive, through health plan design, communication via PCPs, or employer or individual marketing efforts, to steer Kaiser Permanente members away from the ER to lower-acuity settings?

Michael Neri: We have launched an education campaign that explains to members why, when, and where they can access urgent care.

Peter King: Our focus is on providing the right care, at the right time, in the right place to meet the patient’s needs. We do not offer additional incentives. In many cases, a visit to an ER might not be the best option for patients. We have processes in place to guide patients to a more effective venue, based on their condition and preference, which may be an office appointment, a visit to the ACC, or telephone advice.

Alan Ayers: As we see the nation’s health delivery shift from fee-for-service to more integrated models and outcomes-based payment systems, what can the urgent care industry learn from Kaiser Permanente’s experience with urgent care?

Peter King: We believe that the urgent care model will play a significant role as the nation moves toward more integrated, outcomes-based care delivery models. I hope that high-acuity urgent care will become as common as the traditional low-acuity urgent care is today. This model fills a gap between the medical office and the hospital that provides patients with access to high-quality outpatient care. Our experience shows that this model is capable of improving quality, service, and patient satisfaction while making care more affordable for members.

Integrated health systems like Kaiser Permanente’s are defined by their ownership of hospitals, physician practices, and health insurance; financial incentives that align medical cost savings, clinical outcomes, and population health; and coordination of primary and specialist care through an electronic health record. These are also the driving principles of the ACAs authorized by the March 2010 health care reform legislation. As Drs. Neri and King illustrate, when the availability of higher-acuity urgent care matches a patient’s condition with the capabilities of the treating facility, unnecessary ER visits can be avoided, thus promoting the integrated system’s goals of quality and efficiency.

The Role of Urgent Care in an Integrated Care Delivery System: Insights from Kaiser Permanente

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine