Inside Kaiser Permanente’s Collaborations With Home-Based Care Providers

Kaiser Permanente is well known as one of the largest health care organizations in the U.S. It is also becoming more well known in the home-based care community as a payer source that’s more friendly to work with.

“Quality home-based services are absolutely vital to the continuum, and Kaiser Permanente is taking a proactive approach to ensure we’re objectively supporting, managing and collaborating to generate the best outcomes for the region, for our membership,” Bill Gammie, senior director of post-acute utilization at Kaiser, told Home Health Care News.

Gammie previously worked on the home-based care side of the house as an executive director at Seasons Hospice & Palliative Care, which is now a part of AccentCare.


Kaiser is one of the largest health systems and medical groups in the country. Its health plans cover 13 million people across eight states.

Its home-based care network is made up of about 26 agencies, including companies like LHC Group, Bayada Home Health Care and Pavilion Medical Home Care & Staffing.

“We’re working at various levels, and engaging all types of home-based providers,” Gammie said.


One of these collaborations is a system-wide effort to optimize wound care with all of Kaiser’s preferred home health agencies.

“This includes visits, they’re doing assessments, they have licensed wound care nurses, they connect through messaging with wound care doctors to keep the physicians looped in with any changes and the status of the wound,” Nicole Schmidt, manager of Kaiser’s post-acute network, told HHCN.

As part of this effort, Kaiser works on cross-functional teams that involve physicians, discharge planners and partnering home health agencies.

The goal is to facilitate successful transitions of care for members with wounds.

“We work collaboratively to ensure that home health agencies are set up for success when they accept a wound care patient under their service and that there is robust communication regarding start of care and wound care management,” Schmidt said.

Currently, Kaiser is in the process of working on a sepsis program with Bayada. The program is in its early stages.

Pavilion’s heart failure pathway

Kaiser has also teamed up with Pavilion — a diagnosis-focused home health agency that operates in Virginia.

Though Pavilion and Kaiser have been working together since 2009, the heart failure program began roughly a year ago.

The collaboration is centered around establishing a heart failure pathway focused on reducing readmissions, improving well-being and enhancing quality of life.

“This is a population that is considered very high risk, and the cause of readmissions ranges from the complexity of the disease process to social determinant factors at home, so the partnership is geared toward bridging the gap within the care continuum,” Javan Okello, senior director of marketing and business development operations at Pavilion, told HHCN.

The heart failure program is built on a transitional care model, which is meant to address the cause of readmissions and to minimize the fragmentation within the care continuum, according to Okello.

This meant taking into account the complexity of each patient’s needs.

“Case in point, some patients that are at home have caregivers, some live alone,” Okello said. “You will never know which patient is which if you look at it from the diagnosis standpoint — they’re all CHF patients. This was more geared to address those specific gaps. If a patient lives at home, how do we take care of such a patient? What are the factors contributing to that patient’s consistent readmissions to the hospital?”

Pavilion collaborates closely with Kaiser’s cardiologists and discharging hospitals in Northern Virginia.

The program also incorporates Medicare Advantage’s supplemental benefits — such as medication management, home safety visits and nurse practitioner visits.

It also includes real-time data sharing. Having this data allows Kaiser’s team to intervene if they’re needed.

“So far, we’ve been able to successfully keep some members at home due to preventable causes,” Okello said.

Okello believes that this success exemplifies the importance of the sort of collaboration the company has with Kaiser.

“This model is the future, we have to collaborate on each diagnosis,” he said.

Indeed, Gammie also views proactively providing care and support in the home as an avenue to reduce adverse events.

Overall, these partnerships emphasize the importance of care continuity, according to Schmidt.

“We’re really looking at the entire process for this high-risk population,” she said. “What do they need in the hospital? What do they need when they discharge? What can the home health agencies provide? We have home health agencies with really experienced and dedicated clinicians that create these pathways.”

Looking ahead, Kaiser hopes to move these collaborative efforts further into the value-based care arena.

“Currently, we have episodic and per diem payment, but we really want to be able to align and share in the success of the reduction of adverse events and have a reimbursement model that allows home health agencies to make those additional resource investments,” Gammie said.

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