I am a Kaiser patient (a "member"). Recently diagnosed with pre-diabetes, I signed up for a class on this topic. Presumably, Kaiser's goal in offering such classes is lifestyle modification. The benefits would be enormous, both for Kaiser's bottom line and, even more importantly, for the health and quality of life of its patients. Yesterday, I attended the class. What I learned is that health education at Kaiser is merely a formality, and is unlikely to achieve any positive outcomes. This is clearly a missed opportunity. In this essay, I propose some remedial actions that could be taken at Kaiser, and suggest that the payoff -- both to the organization and to its patient members -- would be immense.
These observations and proposals apply to the full spectrum of health education Kaiser offers; not just pre-diabetes but also smoking cessation, prenatal care, pediatric wellness, caregiver support, and so on.
First, it is essential to collect data. What you can't measure, you can't manage. Kaiser's education registration process does not gather (except on a sign-up sheet in the classroom whose sole purpose is to enable the mailing of attendance certificates) any information about who attended, details of their diagnoses (for outcomes effectiveness measurement), how they were reached (which methods of outreach are effective?), etc. Signups should be online or over the phone with data entry by a clerk so that outcomes tracking can be enabled. Registrations should include medical record numbers (MRNs) and data relevant to the topic of the course should be gathered retrospectively and prospectively. In my case, for example, a report should be generated periodically -- say, quarterly -- showing my past and ongoing A1c and blood glucose test results. It would become possible to see whether the intervention (taking the class) was effective, as demonstrated by declining blood sugar values. This would also reveal whether further intervention is required. It would also enable -- on a population-wide basis -- the evaluation of the effectiveness of the intervention. If, as I surmise, it showed that there is no statistical effect on patients who participated, it would become clear that a redesign is needed; the intervention is failing.
Second, a single intervention is rarely effective in achieving lifestyle change. Follow up is essential. Some form of case management should be done, such as a periodic phone call or meeting to review the steps that the patient has (or hasn't) taken, and how it's going. To be effective, education such as this cannot be merely a single event; it must be part of an ongoing process.
Third, rewrite the drab and lifeless course materials and re-engineer the training experience. For example, in the class I took, the materials were a sad list of facts about diabetes and some exhortations to exercise and improve my diet. The experience of attending the class, too, was less than inspiring. The classroom was in a basement -- dark and drab -- there weren't enough chairs, the presentation was a tired Powerpoint with a stapled hardcopy handout (cheap, ugly graphics, not bound, no author attributed, etc.), and the instructor -- though well-meaning and fervent (however, not equipped with current science; clearly her education was decades ago) -- had never received train-the-trainer training; she was kind but didn't know the basics of classroom management. A more compelling experience -- and the allocation of more substantial resources (evidently Kaiser's strategy at present is to get health education crossed off its to-do list at the lowest possible cost) -- could be more effective in producing positive outcomes that, tracked longitudinally, would eventually be demonstrated to pay for itself many times over. For example, if just one of the thirty people in the class I attended is spared a diabetic limb amputation, years of classes would be paid for. But to achieve outcomes like that, much more compelling education -- indeed, lifestyle changing -- experiences are required.
Finally, since the potential benefits are so huge, I propose that Kaiser designate a Lifestyle Czar and create and fund a Department of Lifestyle Enhancement, of which classroom activities are just one modality. Another would be ongoing monitoring and follow up. Yet another would be promotion and delivery of lifestyle-enhancing services. Don't just say, "Join a gym." Build a gym, and staff it with experts -- personal trainers, dieticians, etc. Make it a social experience. Reward attendance. Create extrinsic motivations for the lifestyle changes that are challenging at best and, more often, utterly elusive. Kaiser could be revolutionary.
In sum, with vision, expertise, resources and commitment, there is much that could be done at Kaiser to yield better outcomes for patients and for the effectiveness and finances of the organization itself.
Cartoon by Charles Keller, Dan's Dad
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