Quality

When teen members first visit the Burke Behavioral Health Center in Virginia, they are all asked the same intake questions, ranging from “What do you do for recreation?” to “Does your family have a history of violence?” Their answers help determine the best course of care.

Now, because of a unit-based team project to standardize care for transgender and gender-questioning members, teens ages 14 and older also are asked where they fall on the gender spectrum.

“We included this in the standard behavioral health assessment to normalize it instead of pathologize it,” says Sulaiha Mastan, Ph.D., a licensed clinical psychologist and UFCW Local 400 member. Mastan, who works exclusively with children and adolescents and has about 20 transgender teens in her care, says the information is important for treatment purposes.

For instance, a parent may say a child is depressed and is refusing to go to school. If that child is gender-questioning, gender-nonconforming or transgender, the underlying reason may have to do with changing clothes in the locker room or using the school restroom.

“If I have a teen who says, ‘I have a female body, but I am a male,’ then I am aware,” Mastan says.

High suicide rate

The stakes are high: A 2011 study found that 41 percent of transgender or gender-nonconforming people have attempted suicide sometime in their lives, nearly nine times the national average.

In another change, the unit’s front desk employees now check the electronic medical record to learn each member’s preferred name and pronoun, respecting that a member may, for example, appear male but identify as female.

“At the front desk, we are the first impression,” says Anthony Frizzell, a mental health assistant and member of OPEIU Local 2. “It is imperative that we relate to the patient in the way the patient wishes.”

The UBT also standardized the steps it takes when members are interested in hormone treatments; started a support group on transgender issues for parents; and is developing a brochure that will guide transgender adolescents through receiving care at Kaiser Permanente.

The policies it created follow national and KP guidelines, says Sand Chang, Ph.D., a psychologist and gender specialist in the Multi-Specialty Transitions department in Oakland.

“Although it is not routinely done, this is really falling in line with best practice—to give young people an option,” Chang says.

The project earned the team the R.J. Erickson Diversity and Inclusion Achievement Award at Kaiser Permanente’s 38th National Diversity and Inclusion Conference in October.

The team’s initiatives send the message that wherever a person is on the gender spectrum, it is part of being human, says Ted Eytan, MD, medical director of KP’s Center for Total Health in Washington, D.C.

“What the team is doing is making it very normal,” Dr. Eytan says. “It is something about you that we need to know, rather than something that needs to be extinguished.”

Early in her nursing career, Yvonne Roddy-Sturm, now the chief nursing executive at Ontario Medical Center in Southern California, saw that caregiver diversity—or lack of it—matters.

“I saw differences in how some providers cared for people,” she says. “It wasn’t just based on race—economic status, language, lots of things came into play. We all make assumptions about others.”

The consequences of such assumptions are serious, impacting the quality of care a patient receives and leading to a wide range of health disparities.

In the 30 years Roddy-Sturm has been with Kaiser Permanente, our member and patient population has become more diverse—as has our workforce. And that’s helped KP deliver high-quality, patient-centered care.

“Patients who can relate to their caregiver are more likely to follow their treatment regimen,” says Roddy-Sturm. “They’re more likely to ask questions of people who are more like them.”

The Labor Management Partnership plays a significant role in building the skills, cultural competence and work environment needed to serve KP’s diverse patient population.

For example:

• Unit-based teams provide a more inclusive workplace and give staff members a safe place to speak up.
• Two LMP-sponsored educational trusts provide tuition assistance, paid time off and career counseling to help employees move up the career ladder.

And there’s more. Many departments, including Ontario’s nursing department, make their diverse teams part of the hiring process.

“We always start with the skills required to do the job,” says Roddy-Sturm. “Then our panel members bring their own insights and diversity to the discussion. They look for fit, flexibility, compassion and empathy, as well as skill. We try to live our values.”

Brandon Johnson was close to giving up on his dream of becoming an X-ray technician.

Born with sickle cell disease, a genetic blood disorder that primarily affects African-Americans, the 35-year-old Southern California man was forced to drop out of school for semesters at a time.

But thanks to the sickle cell care team at the Inglewood Medical Offices, Johnson is now on medication that reduces complications. Last fall, he was able to complete his studies, and he has started looking for a radiology job.

“They got me on a plan to keep me out of the hospital,” says Johnson, who drives 60 miles one way from his Riverside home to see his doctor in Inglewood, even though other providers are closer. “If I didn’t have my health, I wouldn’t be where I am today.”

Johnson’s success is not uncommon for the Level 5 unit-based team, a group of physicians, managers and employees that provides personalized care for nearly 500 sickle cell patients in Southern California. About 300 of the region’s adult patients are treated directly by the team. Its approach is working—only five of the 300 needed frequent hospitalization and emergency care in the past year.

“Our goal is to keep sickle cell patients out of the hospital by giving them the care they need,” says Pippa Stewart, Inglewood’s department administrator.

Stigmatized as drug addicts

Nationwide, about 70,000 people have sickle cell disease, which can cause chronic anemia, acute pain, infections and stroke. Although most are African-American, the disease also affects people of Indian, Middle Eastern, Hispanic and Mediterranean heritage. Patients often get stigmatized as drug addicts when they ask for narcotics to deal with their pain.

The current UBT grew out of a team that was established in 1999; before that, there was no comprehensive treatment program for KP’s sickle cell patients.

“Ninety percent of patients were getting their primary care in the emergency room,” says Shirley Brown, RN, a UNAC/UHCP member and the team’s care manager. Patients saw as many as 17 doctors as they went from appointment to appointment.

Now, the 12-member UBT—which includes four physicians, two registered nurses, a physician assistant, a pharmacist and a social worker—helps patients control symptoms by offering pain management care, providing resources such as a case manager, and urging them to keep appointments, which help minimize visits to the emergency room and hospital.

Team members coordinate with and help train the KP providers who care for the region’s remaining 200 patients. Last fall, Brown helped lead a session for 70 registered nurses from around the region. Osbourne Blake, MD, an internist and the team’s lead physician, provides regular updates to fellow physicians. “We’re trying to get everyone on the same page,” says Dr. Blake. A recent test of change focused on reducing the number of patients who miss appointments. For three months, Brown and a co-worker called patients every day to remind them about upcoming visits. The calls helped. The team’s “no-show appointment” rate dropped from 20 percent in May 2015 to 14 percent in August 2015.

Dramatic improvement

“They all know you personally,” says Ryan Hull, a 27-year-old TV production assistant and film student. A few short years ago, he suffered frequent crises that required immediate medical attention. After he and his physician co-created a pain management program, his health improved dramatically.

“They did everything they could to find out what regimen works for me,” Hull says of staff members, who greet him by first name and offer walk-in appointments to accommodate his sometimes unpredictable schedule. “They figured out the perfect way to treat me.”

For the past few years, unit-based teams have been driving a powerful transformation. It’s helping to control chronic diseases; assisting in the early detection of cancer; providing familiarity with a patient’s community; and enabling frontline employees to speak a patient’s language. It creates customized care for each of Kaiser Permanente’s more than 10 million members.

It isn’t a cool new gadget or something out of a sci-fi flick creating the change, but rather a modern care approach that takes into account the infinite number of ways KP members are unique—that emphasizes diversity and inclusion.

“All of us as individuals have all these different multicultural identities, and so do our patients,” says Ron Copeland, MD, senior vice president of National Diversity and Inclusion Strategy and Policy and chief diversity and inclusion officer. “We have to create high-performing teams that work together to deliver culturally responsive care that addresses those differences.”

Increasingly, the workers, managers and physicians working together in UBTs are considering the many facets of individual patients as they transform—in small and large ways—how they care for and serve those patients, using their knowledge and empathy to rethink how we deliver care.

As the stories in this issue of Hank illustrate, some of those changes are aimed at eliminating race- and gender-based health disparities. Other changes are taking place outside our medical facilities—working with school-age children, for example, to give them better food choices and teach them healthy habits that can last a lifetime. 

By doing this, UBT members are ensuring that Kaiser Permanente members are the healthiest they can be no matter their background or beliefs, language or gender, disability or economic status, whether they live in a big city or on a farm.

“UBTs have always led on innovating care by putting patients at the center, listening to them and customizing care for them,” says Hal Ruddick, executive director of the Coalition of Kaiser Permanente Unions. “This work strengthens and deepens that high-quality care.”  KP’s workforce is full of diversity, and UBTs are designed to draw on all employees’ perspectives in deciding how best to do the unit’s work. It’s a natural step to include our members’ and patients’ viewpoints as well. Understanding and considering the complexity of the patients and communities we serve directly affects quality of care and health outcomes.

“It’s about using our knowledge of differences as an advantage to better understand the patients we care for,” says Dr. Copeland. “Our goal is health care equity—so that all our patients achieve optimal health. For that to happen, it’s essential that we have approaches that account for our patients’ unique needs, preferences and living conditions.”