Imagine a world where everyone is healthy.

Transcription

1 2008 community benefit report Imagine a world where everyone is healthy.

2 Our Mission Kaiser Permanente s mission is to provide high-quality, affordable health care services to improve kp.org/communitybenefit the health of our members and the communities we serve.

3 page 4 kp.org/communitybenefit 2008 Community Benefit Report page 5 Letter from Board Member Cynthia A. Telles, PhD Letter from SENIOR VICE PRESIDENT Raymond J. Baxter, PHD Dear Friends and Colleagues: Kaiser Permanente has a long, proud history of social benefit aimed at community health improvement, disease prevention, reduction of health disparities, and the development and dissemination of evidence-based medicine. In fact, community benefit is a central part of our mission. As a nonprofit organization, we dedicate our assets to public and charitable purposes, which include charity care but extend well beyond our clinics and hospitals. This past year alone, more than $1 billion was invested in a multitude of community benefit programs across the country. The proper stewardship of these resources on behalf of the community is a high priority of the board of directors, which leads and oversees this critical work. In 2001, the board conducted a sweeping review of our community benefit activities and resolved to strengthen the program and to answer key questions about health and health care in America. In 2002, the board established a standing community benefit committee to provide strategic direction and oversight for this work. The committee formulates the vision; oversees the design of initiatives; approves community benefit spending plans, large grants, and regulatory filings; evaluates major community benefit initiatives; and assesses the performance of the program. Each year, the committee develops priorities that are responsive to the evolving needs of our communities, such as caring for the uninsured, measurably improving community health, eliminating racial and ethnic disparities, elevating the quality of care in Medicaid, and becoming a model for environmental stewardship. This past year, our nation faced severe economic challenges, which created a disproportionate burden on the most vulnerable. Government funding cuts have severely strained the safety net and the community clinics, and, at the same time, the demand for food, medical care, and social services has increased dramatically. The community benefit committee is committed to ensuring that Kaiser Permanente will be a reliable partner in working with communities to find solutions to the immediate crises and to advocate for policy change that will create a better future. We offer our gratitude to our community benefit staff for their dedicated work, to our employees and physicians for their extraordinary volunteer work in our communities, and to our partners and grantees for their remarkable efforts. Most important, we applaud the many highly devoted people in our communities who have labored with courage and tenacity to enact change that will provide quality health care and promote health for all Americans. Together, we will strengthen our communities and thrive! Sincerely, Cynthia A. Telles, PhD Chair, Community Benefit Committee Board of Directors Kaiser Foundation Health Plan, Inc. Kaiser Foundation Hospitals Dear Friends and Colleagues: At the beginning of 2008, approximately 46 million people in the United States were uninsured comparable to the population of 23 states. This year, many more are joining the ranks of the uninsured as a result of the economic crisis we currently face. In response to these very challenging times, we are strengthening the communities we serve by improving access to high-quality health care and investing in the creation of healthy environments. I invite you to review this report on our community benefit activities and performance in Kaiser Permanente invested more than $1 billion to provide health coverage to those in need, drive improvements in community health, reduce health disparities, strengthen our partnerships with community-based organizations and help make total health a reality for everyone. As the economy deteriorated in 2008, and more people lost their jobs and health benefits, enrollment in our Charitable Health Coverage programs grew by 16 percent, with yearend enrollment surpassing 100,000 members. All of our regions now offer at least one charitable coverage program tailored to the unique needs of their local communities. We reinforced our participation in government programs for low-income individuals and families, and provided care to more than 300,000 Medicaid and Children s Health Insurance Program members, an 11 percent increase in membership over the previous year. We also continued our commitment to reshaping the social, economic, and environmental conditions that affect the health of our communities. Last year, we were either the principal sponsor or cosponsor of intensive, placebased Healthy Eating Active Living initiatives in 40 communities. We re helping to build vibrant neighborhoods because we believe that healthy communities and healthy environments are critical to individual health and wellness. All in all, we provided grants to 2,414 organizations in our communities last year. Our commitment to improving the health of the communities we serve has been part of Kaiser Permanente s mission for more than 60 years. This report details just a few of the things we did to help make better health a reality for everyone during What others can only imagine, we pursue as a reality. We hope this report will help you learn more about our programs and the communities with whom we are engaged. Sincerely, Raymond J. Baxter, PhD Senior Vice President, Community Benefit, Research and Health Policy Kaiser Foundation Health Plan, Inc. Kaiser Foundation Hospitals Committee Members: John August Thomas W. Chapman, MPH, EdD John H. Cochran, MD J. Eugene Grigsby III, PhD Judith A. Johansen, JD Kim J. Kaiser Sandra P. Thompkins, JD

4 page 6 kp.org/communitybenefit Executive Summary... 8 The Evolution of Community Benefit Access to High-Quality Care Care and Coverage Safety Net Partnerships Healthy Environments Community Health Initiatives Environmental Stewardship Developing and Sharing Knowledge The David Lawrence Community Service Awards Table of Contents 2009: Meeting the Challenges. Maximizing the Opportunities Community Benefit by the Numbers... 58

5 page 8 kp.org/communitybenefit 2008 Community Benefit Report page 9 Executive Summary The Kaiser Permanente community benefit programs saw significant progress and growth in Highlights include: A 16 percent increase in Charitable Health Coverage programs. Funding for the first virtual school that will allow students from all over the world to learn from experts about patient safety and effective care from each other. The expansion of place-based Healthy Eating Active Living initiatives from 27 to 40 communities across the country. Our community benefit expenditures in 2008 totaled nearly $1.18 billion, an increase of approximately 12 percent over 2007, and equaled 78 percent of our operating income of $1.5 billion. We Believe Everyone Has the Right to Quality Health Care Our mission extends beyond our 8.6 million members. As one of America s leading health care providers and nonprofit health plans, we believe that everyone has the right to quality health care. Founded in 1945, our mission is to provide high-quality, affordable care to improve the health of our members and the communities we serve. Each day, we commit our resources to helping the most vulnerable people in our communities gain access to care. Public programs like Medicaid and the Children s Health Insurance Program, and our own programs like Medical Financial Assistance, safety net partnerships, and Charitable Health Coverage, work together to create a web of access to high-quality care, particularly for those most in need. They fill coverage and access gaps, create highimpact programs, and inform public policy. As the recession loomed in 2008, we expanded access to our Charitable Health Coverage programs, with total membership topping 104,274 by year-end. All of our regions now offer at least one charitable coverage program tailored to the unique needs of the local community. Additionally, in 2008, we provided care to 300,636 Medicaid and CHIP members which is 24,008 more members than in Since we can t meet the growing needs of the uninsured and underinsured alone, our safety net partnerships emphasize capacity development and the cultivation of evidence-based practices that are efficient and effective. By building toward a safety net system that provides coordinated, safe, and quality care, we are helping to support the needs of our communities. Kaiser Permanente s continued partnership with the Institute for Healthcare Improvement provided 200 training scholarships in 2008 to clinical scholars from the safety net whose institutions would otherwise not be able to afford the expense of the trainings. We also worked with IHI to help create the first virtual or open school that will allow students from all over the world to learn from experts and each other about patient safety and effective care. Total Health in Mind, Body, Spirit and Now, Planet At Kaiser Permanente, we believe in disease prevention and health promotion, not only for our members and the communities we serve, but for the world around us. Through our grants and partnerships with local organizations, we support comprehensive, sustained intervention to change a community s health. For example, our community health initiative for Healthy Eating Active Living is building parks and bike paths to promote walking and biking in communities across all of our regions. By building community gardens and nurturing farmers markets in communities lacking grocery stores, we improve people s diets, support sustainable agriculture, and reduce the distance between farm and fork. This not only promotes good health, but also reduces greenhouse gas emissions. Our employee engagement program also

6 page 10 kp.org/communitybenefit 2008 Community Benefit Report page 11 includes park revitalization projects and cooperation with local environmental organizations. In 2008, we sponsored intensive, place-based HEAL initiatives in 40 communities up from 27 in In total, we invested $20.1 million in 2008 in community health initiative grants for 1,181 organizations. Our regions also supported community health initiatives with extensive technical assistance, including obesity prevention expertise provided by our physicians and staff. Environmental stewardship has become integral to Kaiser Permanente s business strategy and operations. During 2008, we established guiding principles, organizational operating commitments, and actions to improve the health of communities we serve. For example, our sustainable purchasing efforts support the health of members while reducing environmental damage. We use environmentally friendly, latex-free, PVC-free, nitrile exam gloves. We installed more than 100 acres of reflective roofing to reduce cooling costs. Over the past several years, we purged nearly 1,400 pounds of mercury from our facilities; and as of the end of 2008, we are 95 percent mercury-free. We also refurbish or resell approximately 44 percent of our electronic equipment. The remainder of the equipment is disassembled, so the components are fully recycled. Most of our environmentally preferable product decisions are either cost-neutral or cost less than the more toxic products, supporting our commitment to providing affordable health care. We are already making significant progress in our efforts to reduce our carbon footprint. We are finding safe alternatives to hazardous chemicals and materials, designing and building high-performance medical facilities, driving sustainability throughout our supply chain, and engaging employees and physicians in activities that reduce their impact on the environment. For our efforts to reduce waste and prevent pollution, we won 12 awards at Practice Greenhealth s global conference, CleanMed Spreading Health by Spreading Knowledge One of the best ways to help keep more people healthy is to share the knowledge created by the assets of our organization. We create knowledge by nurturing scientific research, and translating research into clinical practice. Our findings contribute to science and medical practice, inform the training of the next generation of health care professionals, and empower our members with knowledge about their own health. Last year, our researchers published more than 700 studies. These studies cover a wide range of topics and take advantage of the unique database of longitudinalhealth information available only at Kaiser Permanente. The findings of this research in 2008 informed diabetes prevention and treatment, strategies for weight-loss management, and potential signals of the onset of dementia. Our Research Program on Genes, Environment and Health is contributing to public health by taking the work of the Human Genome Project describing the sequence of genetic information in great detail to the next level by understanding how genes, behavior, and the environment interact to influence health. Education A Powerful Tool for a Healthier Future Educating the health care providers of tomorrow is essential to shaping the future of health care. Our medical residencies attract graduates from the top medical schools in the country. In addition to training in state-of-theart medical offices and hospitals, fully supported by electronic health records, many residents have rotations at community clinics, where primary medical care services are provided for low-income families, the homeless, and other underserved populations. This gives residents a better understanding of the barriers that some communities have to health care, as well as the resources that could be available in a reformed, equitable health system. Our Educational Theatre Program is a potent strategy for disseminating our clinically honed prevention messages to students, families, and their broader communities. ETP is free to schools and the community. During 2008, the program educated more than 557,000 children and 121,000 adults. Using live theatre, music, comedy, and drama, ETP engages kids, teens, and adults on a wide range of subjects, including healthy eating, physical activity, diversity, conflict resolution, dealing with grief and loss, sexually transmitted diseases, literacy awareness, and alcohol and tobacco. Our employee engagement programs also spread health beyond our clinical environments. For example, on Martin Luther King Jr. Day nearly 5,000 Kaiser Permanente employees and physicians volunteered their time and skills at 79 sites across all eight of our regions, providing services that directly impact the lives of people in our communities. As one of America s leading health care providers and nonprofit health plans, we believe that everyone has the right to quality health care. Founded in 1945, our mission is to provide high-quality, affordable care to improve the health of our members and the communities we serve.

7 page 12 kp.org/communitybenefit 2008 Community Benefit Report page 13 The evolution of community benefit A history of innovation 1 Care and coverage for low-income people Kaiser Permanente believes everyone has the right to quality care and coverage. We create and support programs that lower financial barriers so that the uninsured and underinsured can gain access to the care we provide. We accomplish this through the provision of charity care, free or subsidized coverage, and enrollment in Medicaid, CHIP, and other public programs (e.g., Medicare Limited-Income Subsidy). A Total Commitment Toward Total Community Health Kaiser Permanente s heritage of caring for local communities is fundamental to meeting the complex health care challenges we face today. Our diverse portfolio of community benefit investments ranges from research and education, to participation in public and private programs for the underserved, to grant support for communitybased organizations. We focus our community benefit services, partnerships and funding on four core areas: 1. Care and coverage for low-income people 2. Safety net partnerships 3. Community health initiatives 4. Developing and disseminating knowledge These streams of work are increasingly integrated with one another and can adapt to different community circumstances. They provide the framework for our investments in communities. 2 Safety net partnerships Kaiser Permanente is committed to building partnerships with community clinics, local health departments, and public hospitals. Through funding, technical assistance, influencing public policy, training and volunteering, and dissemination of care-management and quality-improvement technologies, we help these vital health care providers improve care and expand treatment capacity for the communities and vulnerable populations they serve. 3 Community health initiatives Kaiser Permanente s community health initiatives seek to measurably improve the health of the communities that we serve. As an innovator in health, we design, deliver, and sustain long-term programs that engage communities in work to improve the conditions in their neighborhoods, workplaces, and schools that can support good health, particularly Healthy Eating Active Living. 4 Developing and disseminating knowledge Kaiser Permanente is dedicated to advancing health through research, education, and training. We aim to improve health care by sharing our knowledge, educating practitioners, advancing research, empowering consumers, and informing policymakers about the evidence base for care and health. Morris Collen, MD Health Screenings Led to Innovation in Health Information Technology Kaiser Permanente has long been at the forefront of using information technology to advance health care. In the early 1960s, one of our physicians helped to lay the groundwork for the current data systems that have evolved to include Kaiser Permanente HealthConnect, the largest civilian electronic health record system in the United States. In 1961, Morris Collen, MD, began leading a new research arm today s Division of Research to explore the use of all possible electronic aids in diagnostic work and treatment to expand the scope of preventive medicine across the program. A year later, Dr. Collen received a three-year, $900,000 grant from the United States Public Health Service to computerize and study the effect of an annual check up on preventing disease. With the medical information punched on cards and fed into a computer, Dr. Collen and his team began building what later became one of America s largest research databases. During the next decade, Dr. Collen and others built a research program that showed preventive care could indeed improve health and longevity. Publications of the results brought prestige to the program and spawned replicas of the multiphasic around the world. At 95, Dr. Collen continues his work at the Kaiser Permanente Division of Research in Oakland, Calif. harnessing the power of KP HealthConnect and computers to improve health care. He also studies the effects of drug interactions among elderly patients. Today, KP HealthConnect connects 8.6 million of our members to their health care teams, their personal health records and the latest health information. Every month, the system supports nearly 600,000 s between our doctors and our members.

8 page 14 kp.org/communitybenefit 2008 Community Benefit Report page 15 Access to high-quality care Care and Coverage Opening the Door to Opportunities for Good Health Improving access to care for vulnerable populations is fundamental to Kaiser Permanente s mission as a nonprofit organization. We believe everyone regardless of income deserves quality health care and we believe that healthy people create stronger communities. This year s unprecedented economic downturn has resulted in millions of people losing employerbased coverage. We are working to address the challenges this presents to our members and our communities. Public programs like Medicaid and Children s Health Insurance Program and our own programs of Medical Financial Assistance, safety net partnerships and charitable coverage all work together to create a web of access to high-quality care for those who are losing their health coverage. In 2008, we provided care and coverage to more than half a million low-income adults and children who did not have insurance. At the end of 2008, 104,274 people were members covered through our innovative Charitable Health Coverage programs; almost 30,000 more people received traditional charity care in our hospitals and clinics; and an additional 300,636 people received care through Medicaid and the CHIP. Charitable Health Coverage: A Medical Home for the Uninsured At the beginning of 2008, there were roughly 46 million uninsured people in the United States. Those who are not eligible for public programs often have to rely on traditional charity care for their health care obtaining care wherever they can for acute episodes of illness or injury. Frequently, they wait to seek medical care until their conditions become critical. Often, they end up in hospital emergency rooms for treatment of conditions that could have been easily prevented with the right treatment and timely care. That is why we created the Charitable Health Coverage programs. Our Charitable Health Coverage programs are a unique approach to caring for low-income, previously uninsured people, tailored to the needs of the communities we serve. Participants receive a regular Kaiser Permanente membership card, and access to the full range of our services and providers a much better alternative to a brief and costly emergency room visit or hospitalization. This allows us to invest in the longer-term health of our patients and our communities. Kaiser Permanente s Charitable Health Coverage Programs REGION Program Eligibility Guidelines Northern California and Southern California Colorado Georgia STEPS Child Health Plan (CHP) Connections Safety Net Access Program Bridge Plan of Limited Duration Since the early 1980s, Charitable Health Coverage programs have made a real difference in the lives of more than half a million low-income people who might otherwise have no source of coverage. With 12 innovative programs across the country, Charitable Health Coverage provides the care people need and subsidizes 80 to 100 percent of the cost for a minimum of two years. This gives qualified individuals a medical home where they can receive continuous and comprehensive care from our physicians and staff the same high-quality care provided to all of our members nationwide. Members under 300 percent FPG* whose coverage has been terminated in the past six months Birth 19 years of age, and under 300 percent FPG Adults and families under 250 percent FPG. The program is targeted toward members whose coverage is terminating and to referrals from community partner agencies Unique collaboration with two community safety net partners to care for the uninsured within the community setting Adults and families under 300 percent FPG from targeted partner agencies Adults under 300 percent FPG completing two years of Bridge Plan Coverage Hawaii Bridge years of age under 250 percent FPG Mid-Atlantic States Northwest Bridge Child Health Partnerships Transitions Child Health Program Adults and families under 250 percent FPG Birth 18 years of age under 250 percent FPG in collaboration with county initiatives Adults and families under 250 percent FPG in targeted community colleges K 6th graders plus siblings age 3 to 12th grade under 250 percent FPG in targeted low-income schools Washington Basic Health Plan Subsidy Limited to participants in the Washington State Basic Health Plan Ohio Transitions Adults and families under 250 percent FPG * Federal Poverty Guidelines are annually determined by the Census Bureau, based on family size and income. For example, 250 percent of FPG for a family of four in 2008 was approximately $53,000 per year. See Caring for the Most Vulnerable In 2008, our Northern California children s health plan was recognized by the Santa Clara County Board of Supervisors. We enrolled 740 uninsured children who were on the waiting list for the county s Healthy Kids Program. These children now have free or deeply discounted coverage from us and will receive their care in our facilities.

9 page 16 kp.org/communitybenefit 2008 Community Benefit Report page 17 Since 2003, spending on Charitable Health Coverage has grown by $145M Since 2003, membership in Charitable Health Coverage has grown by 62,373 members (249 percent) community journal MISSION MEDICAL CENTER: Lawrence s story M I L L I O N S $0 $40 $80 $120 $160 $200 $ $76.2 $84.6 $ $ $ $220.7 M E M B E R S H I P 0 20,000 40,000 60,000 80, , , ,901 39,696 51, , , ,274 Lawrence Lucero was homeless and living on the streets of Colorado Springs, Colo., when he first heard about Mission Medical Clinic, a safety net clinic supported in part by Kaiser Permanente. Lawrence knew he was in need of serious medical help. He suffered from severe diabetes, hypertension, and high cholesterol levels, and had to be rushed to a nearby hospital where he ended up staying for eight days. I was very ill in the hospital and it was very up and down about my health situation, he says Charitable Health Coverage Spending Economic Challenges Addressing the Needs of Our Communities In response to this year s economic crisis, it was important for us to react quickly to rapidly increasing demands. In November, we introduced a new Charitable Health Coverage program in Hawaii, focusing on caring for lowincome young adults. In all regions we had to develop new partnerships, streamline administrative procedures, and increase visibility in our communities in new ways. As a result, between August and December 2008, we were able to add 10,627 new members to our programs who otherwise would not have health coverage. Total year-end membership in these charitable coverage programs was 104,274. This represents a 16 percent membership growth and total subsidy costs of $221 million Charitable Health Coverage Membership Safety Net Partnership Model in Colorado Springs Last year, we forged a unique partnership in Colorado Springs, Colo., to develop a charitable coverage program in collaboration with two volunteer safety net clinics: Mission Medical Clinic and SET Family Medical Clinic. Mission Medical Clinic and SET Family Medical Clinic are nonprofit, faith-based organizations with missions to serve the uninsured and homeless in the Colorado Springs community. Both have served the community for many years, primarily using volunteers from local churches to provide primary care and access to pharmaceuticals. Collaboration with the two community hospitals and a volunteer specialty network helps connect the area s estimated 100,000 uninsured with other needed services. Yet limited hours of operation and lack of access to a consistent volunteer provider was a challenge, especially for those with chronic illnesses needing ongoing management. However, he didn t fully appreciate how serious his situation was until he met Rebecca Ricchi, a nurse practitioner, and the rest of the medical team at Mission Medical Clinic. After he was released from the hospital, he continued to work with Rebecca to manage his diabetes and his general health. Rebecca made me realize what a nasty disease diabetes is, said Lawrence. Lawrence worked with Rebecca and the rest of his medical team for several months to keep his diabetes under control. He also made use of the eye clinic and the dental clinic. The clinical staff helped Lawrence, and many others like him, gain access to a full range of high-quality health services. These services are particularly important for those who have chronic conditions that can turn into life-threatening situations. I can t thank all of the staff at Mission Medical Clinic enough for their concern and expert knowledge in treating me. I m now living a healthy life once again. Today, Lawrence is no longer homeless and lives with his son, who helps take care of him. I owe them my life, he says.

10 page 18 kp.org/communitybenefit 2008 Community Benefit Report page 19 P E R C E N T A G E S 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% community journal bridge program: Kim s story Breast Cancer Screening Cervical Cancer Screening Childhood Immunizations Colorectal Cancer Screening Diabetic Eye Exams Diabetic Screening Hemoglobin A1C 73.5% 82.2% 85.4% 2008 Kaiser Permanente Charitable Health Coverage compared to the top quarter of commercial health plans nationwide. Kaiser Permanente Charitable Coverage Plans National Committe for Quality Assurance Commercial 75th Percentile 2008 We provided the clinics with additional staffing, educational materials, and consultation on quality and continuity of care. The clinics leveraged our investment into an increase of eight paid-staff positions at Mission Medical and an additional 4,210 patient visits and 2,296 chronic condition visits. The model implemented in Colorado Springs has added a more continuous and prevention-based approach to care for those dealing with a lack of coverage and chronic conditions. A three-year evaluation of the impact of the program is underway. 59.8% 62.3% 63.6% 64.2% 86.2% 84.8% 84.6% 91.0% 91.2% Achieving a Higher Standard of Care for Everyone The quality of care provided to individuals who may otherwise lack a regular source of care is comparable to or exceeds the national benchmarks for preventive care services. Regular monitoring of outcomes provides assurance of quality care delivered and highlights opportunities for improvement. My husband and I are hard-working people who have always been able to pay our bills and support ourselves. We don t live extravagantly or above our means, says Kim, who, along with her husband, has been a self-employed realtor for many years. After researching options for buying their own health insurance policies, they chose Kaiser Permanente. The doctors were great; the all-under-one-roof facility was so modern and convenient. We loved being able to take our son to the pediatrician, get a physical for ourselves, have X-rays taken, and pick up medication all at the same place, Kim says. The premiums were affordable for Kim and her husband, until the bottom dropped out of the housing market. Unable to pay their bills or find jobs, they had to drop their health coverage in September of 2008 becoming uninsured for the first time in their lives. Kim decided to return to school hoping to get a better job in the future. It was there that she learned about the possibility of affordable health insurance offered by the school. I figured the insurance offered would either be terrible coverage, or the premiums would be unaffordable, she says. However, I knew it wouldn t hurt to find out, so I attended the meeting, and I was amazed. I still can t believe that, not only is it Kaiser Permanente insurance being offered, but it s incredible coverage that we could only dream about, and at a monthly premium that even we could afford! Through Kaiser Permanente s Bridge Program in Georgia, Kim and her family were able to get the health insurance they needed. I can only say that I am incredibly grateful for the timeliness of this offer, says Kim. It will get us through this rough patch in our lives until I can get a nursing job and be able to purchase insurance again. And, I can promise that if given a choice, I ll continue to stay with Kaiser Permanente. Thank you so much!

11 page 20 kp.org/communitybenefit 2008 Community Benefit Report page 21 Kaiser Permanente Medical Financial Assistance Policy Medical Financial Assistance is another way we help low-income, uninsured and underserved members receive care. Our program is among the most comprehensive in health care. Through our charity care policy, we are committed to: Provide free care for medically necessary services to low-income individuals in our regions up to 200 percent, and in some regions up to 350 percent, of the federal poverty guideline.* However, families or individuals with higher incomes may qualify on a case-by-case basis. In the event the individual or family does not qualify for free care, subject to certain limitations, they may be offered a discount if their income is at or below 400 percent of the federal poverty guideline. In some instances, an uninsured person not eligible for MFA could qualify for up to a 70 percent discount. Not take legal action for nonpayment of medical bills against any person who is unemployed and without other significant income. Offer financial counseling to determine if a patient is eligible for public assistance or our financial assistance. Not place a lien on any patient s primary home. * Federal Poverty Guidelines are annually determined by the Census Bureau, based on family size and income. For example, 250 percent of FPG for a family of four in 2008 was approximately $53,000 per year. See Medical Financial Assistance Our Medical Financial Assistance program provides temporary financial assistance to patients who receive health care services from our providers. Medical Financial Assistance is generally available to those patients in greatest financial need, and covers those earning below 400 percent of the federal poverty level. The program also contributes to community health through strategic community partnerships such as Community Surgery Day and the Dental Smiles program in our Northwest region. In 2008, we dedicated $86.4 million for subsidized medical care through medical financial assistance and discounts for the uninsured. Advancing Access to Care through Public Programs Throughout 2008, we worked to expand access to highquality coordinated care for low-income families through ongoing participation in publicly funded programs like Medicaid and CHIP. While access to high-quality care is important to all of our members, it s particularly relevant to our Medicaid and CHIP members who are struggling to make ends meet with low incomes, while dealing with issues like safe housing, affordable transportation and food security. Membership Expansion for 2008 As job losses mounted in 2008, our enrollment in Medicaid and CHIP grew as well. The expansion of these programs reflects our commitment to be responsive to the economic crisis and the toll it has taken. Medicaid membership grew by over 13,090 members representing an 8.7 percent increase over last year. Our CHIP program grew by 10,918 members, an 8.6 percent increase. As a result, we provided care to 300,636 Medicaid and CHIP members, more than 24,008 members above 2007 levels. Impact of Unemployment Growth on Medicaid and State Children s Health Insurance Program and the Uninsured 1% increase in unemployment = 3 4% decline in state revenues Source: Stan Dorn, Bowen Garrett, John Holahan, and Aimee Williams, Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses, prepared for the Kaiser Family Foundation Commission on Medicaid and the Uninsured, April 2008 Improving Care for Medicaid Beneficiaries We are committed to improving the way Medicaid beneficiaries receive care, not only through our facilities, but also in the communities we serve. Identifying successful practices is important not only for us, but also for state programs across the country. In 2008, we continued our strategic partnership with the Center for Health Care Strategies, a highly regarded Medicaid policy organization. Under the fouryear Rethinking Care program, the center is working with states to test new care management approaches for their highest-need, highest-cost beneficiaries. The goal is to promote better care for the 5 percent of Medicaid beneficiaries who drive 50 percent of total program spending. The Medicaid Learning Initiative is our own program to provide effective service and coordinated care to our Medicaid members, in particular those with multiple chronic conditions, or multiple needs. The Center for Health Care Strategies has provided technical support to the five care management pilots we launched in Northern California: Medicaid Care Coordination The purpose of the Northern California pilot is to improve quality, access, and efficiency of services provided to complex, high-risk Medicaid (Medi-Cal) members, and to improve the Medi-Cal member experience. Health professional teams in four service areas address complex medical, mental health and socio-economic needs and conditions by supporting adherence to care plans. Each team is comprised of a registered nurse, a licensed social worker and two licensed-vocational nurses under the direction of experienced clinical managers. The teams intervene to facilitate access to services and programs; improve understanding and use of medications; reduce the need for hospitalizations; reduce avoidable emergency department use; provide education; and support self-care. An interim analysis demonstrated a downward trend in emergency department use among members who had teams involved in their care. Southern California: Complex Case Management Our pilot in Southern California provides telephonic shortterm intensive case management support to high-risk adult Medicaid (Medi-Cal) members identified by a predictive model. The model allows the team to proactively interact with members to prevent hospitalizations. Specially trained nurse case managers work directly with members, their primary care provider, and the rest of the health care team to improve care coordination. The program aims to improve members health and decrease emergency department visits and hospitalization.

12 page 22 kp.org/communitybenefit 2008 Community Benefit Report page 23 Northwest: Member Navigator In anticipation of increased Medicaid membership in 2009 in the Northwest, Kaiser Permanente is piloting a member navigator program to assist new Medicaid members in finding their way around our system. The navigator will make sure members have a designated primary care provider and understand how to make appointments, transfer prescriptions, obtain mental health services which are outside of our system contact an advice nurse, and obtain assistance with transportation. Colorado: Enhanced Care Management Our Colorado pilot creates an enhanced care management model for special needs Medicaid members in two counties within the region s service area: Denver and Jefferson. Two teams, each with a registered nurse, social worker, and community specialist, coordinate members medical, behavioral, and social service needs within the system, as well as with external service providers. The pilot builds on the best aspects of both a medical home model and a complex care coordination model so that these members and their caregivers will have access to the right care in the right place at the right time. Hawaii: Healthy Beginnings In Hawaii, our pilot focuses on high-risk pregnancies. The Healthy Beginnings program establishes a formal referral process to case managers for high-risk pregnant women who are covered under QUEST, the state s Medicaid plan. These expectant mothers are engaged in a case management program that supports a healthy pregnancy and aims to reduce the number of infants who need neonatal intensive care. The region has also begun a pilot to reduce unnecessary emergency department use by educating families regarding how best to use primary care services. Each region will evaluate its program, with results expected in 2009 and 2010, with the intention to learn from these pilots and adopt best practices. The Center for Health Care Strategies will conduct an overall qualitative evaluation of the programs. We are committed to improving care, not only through our facilities, but also in the communities we serve. Safety Net Partnerships Giving Our Partners the Support They Need to Help Others At the beginning of 2008, nearly 46 million people were medically uninsured in the United States. Twelve months later, while the country suffered from an unprecedented historic economic crisis, hundreds of thousands more people found themselves included among the ranks of the medically indigent. Our nation s safety net, a loose network of community health centers, public hospitals, free clinics, and public health systems, is now faced with the growing demands of the newly uninsured. All of the regions we serve are dealing with unprecedented challenges. As the number of uninsured Americans has increased, so have the pressures on safety net organizations to provide quality care in the face of cutbacks in public finance. States across the country are responding to historic deficits by cutting assistance to low-income families and health care organizations that serve vulnerable populations. We remain committed to strengthening our partnership with the safety net, offering financial, technical, and clinical support. Our strategic partnership community health centers, public hospitals, and local health departments emphasizes capacity development, sustainability, workforce and leadership development, and the cultivation of evidence-based practices that are efficient and effective. We support the safety net s goal to provide coordinated, safe, quality care that meets the needs of patients, their families, and the communities in which they live. Building Capacity One of our goals in partnering with the safety net is to help build capacity. For example, in Southern California we launched the Building Clinical Capacity for Quality initiative in This unique undertaking brought together dozens of safety organizations to explore the full potential of electronic health records. Since the initiative s inception, Kaiser Permanente has provided more than $1 million to it. In 2008, a second phase of collaboration was initiated, bringing together a new corps of experienced clinical leaders who will guide the development of an electronic health record for the tens of thousands of patients who are cared for by community health centers in Southern California. Similarly, in Northern California, we have supported the regular convening of frontline staff in clinics and hospitals to understand how best to use electronic databases to manage patients with chronic and complex needs. In partnership with the Institute for Healthcare Improvement, we have provided more than $1.5 million over four years to fund the top-tier learning and professional development to 830 clinical scholars from the safety net. In 2008, we supported IHI training for 200 clinical scholars who utilized their training to help improve clinical access to the homeless, reduce infection hazards in public hospitals, and reduce wait times for patients. In Hawaii, Kaiser Permanente provided $25,000 in 2008 for the planning and development of Kona Hospital s Emergency Department on the Big Island of Hawaii. A state-of-the-art emergency department will save precious and potentially life-saving time for the residents on the Big Island, many who live hours away from the main hospital facility in Hilo.

13 page 24 kp.org/communitybenefit 2008 Community Benefit Report page 25 Access to Surgical Services Even when patients have a source of primary care, they may lack the resources to access surgery and other specialty services. Our long-standing relationship with Operation Access and our own independently organized Super Surgery Days provide hundreds of uninsured patients with surgical services so they can return to work and good health. For instance, working in partnership with Operation Access, founded by our physicians, 480 of our physicians and employees provided 467 surgical and specialty services in the Northern California region. Similar programs are ongoing in Southern California and the Northwest. Sustaining an Important Social Resource The safety net is particularly vulnerable to the fluctuations of the economy and government support. For example, when Grady Memorial Hospital, the public hospital for Atlanta, Ga., was faced with funding shortfalls, we recognized its importance and made sure that this important institution could continue to fulfill its mission. Of our $5 million grant, $3 million was designated to care for the underserved with chronic conditions and $2 million was for trauma and emergency care. For decades, our physicians have been providing clinical services to underserved populations through arrangements with community health centers. In Southern California, as just one example, six family practice residents are chosen annually through a highly competitive process to participate in a year-long fellowship involving clinical responsibilities in a network of partner community health centers. In addition to clinical responsibilities, the fellows also identify a project that will expand and sustain services to the underserved. In Colorado, our Reach Out Fellowship Program placed 15 physicians and nurse practitioners in community clinics to work side-by-side with the clinical staff at these sites, building practices that serve the medically uninsured. A Model of Community Benefit: La Maestra We recognize that healthy communities and a healthy environment are critical to individual health and wellness. That is why helping to create a healthy environment is central to our mission. It is a vision shared by one of our community partners, La Maestra Community Health Centers. La Maestra, a safety net provider with facilities in the San Diego, Calif., area, advocates total health and wellbeing. La Maestra provides physical, mental, and dental care, as well as new programs and services vitally needed by the community. We awarded La Maestra a $1 million grant to expand access to the uninsured. The contribution is the largest grant La Maestra has ever received from any single donor, and the largest grant we have ever given to a San Diego nonprofit organization. The funding will support La Maestra s construction of a new 34,660 square-foot, stateof-the-art green facility in an underserved community. It will be able to accommodate an estimated 180,000 patient visits per year, more than three and one half times the current number. The facility will anchor a community economic development initiative. La Maestra s construction of a green health center demonstrates its commitment to environmental health as well as personal well-being. The new center will be energy efficient and showcase a healthy facility for patients, employees and volunteers. The facility will comply with the gold-level LEED (Leadership in Energy and Environmental Design) certification offered by the U.S. Green Building Council. This means that the facility will be designed to meet some of the highest environmental standards when it comes to air quality ventilation, lighting, energy-use sources, waste management and natural materials. community journal La Maestra: alma s story Alma Duran has been a longtime patient and supporter of La Maestra Community Health Centers. She says being a volunteer is her way of giving back for the many benefits she has received through the clinic setting. The satisfaction she gets is particularly gratifying to Alma because she first came to La Maestra over a decade ago. At the time, she was pregnant with her second child, and didn t know where to go for prenatal care. Then a friend told her about La Maestra Community Health Centers. At the time of my pregnancy, La Maestra not only provided me with medical care, but also helped me apply for health insurance. The clinic has helped my family in so many ways, says Alma. Alma explains that La Maestra s strength lies in how community residents feel free to come into the clinic, where people understand their culture and their language. The doctors really care about the people. They are very humanitarian and go above and beyond the call of duty way above just their job description, she says. Through the years, Alma has continued as a patient and as a volunteer. She now serves as a volunteer board member, describing it as a way to give back and to help others. She has assisted with the annual holiday season food and toy drive and with fundraising events in support of La Maestra. She believes that it s the responsibility of each individual to take care of others. We have become a part of their family, and I know I am not the only patient that feels this way. La Maestra is a special place, says Alma. She s proud she can give back as a way of showing gratitude. I will always be giving back to La Maestra.

14 page 26 kp.org/communitybenefit 2008 Community Benefit Report page 27 Bridging Innovation with Evidence Across the country, the safety net faces a critical lack of physicians who provide specialty care to low-income patients. Because of this, many patients are receiving delayed diagnosis and treatment. In California last year, we launched a specialty care initiative in partnership with the California Healthcare Foundation. The goal was to develop models for improving the access patients in community clinics and public hospitals have to specialty care. Twenty-three coalitions of safety net providers have received funding to expand the supply of available services and strengthen the coordination of care. As a result of the initiative, safety net providers across the state are sharing best practices and developing a common understanding of the challenges they face. The specialties patients are having the hardest time accessing are neurology, orthopedic surgery, and dermatology. Tools the coalitions plan to implement to address these challenges include common referral forms, a Web-based referral system, standardized metrics, and shared specialist networks. We are also helping to integrate advanced information technology for our safety net partners. We have nationally recognized medical interpreter services at Kaiser Permanente. Still, there are times when a health care team might find it difficult to locate a live interpreter for a language that is infrequently encountered. By working with the Safety Net Institute and the California Medical Interpreters Network, we re supporting a system that allows patients to be connected with an interpreter through a real-time video exchange, even when the interpreter is located 100 miles away! The system is now being used by a number of public hospitals in California, allowing them to save time and money by sharing their resource of qualified interpreters. A whole range of languages are available through the video interpreting system, including Armenian, American Sign Language, Cantonese, Mandarin, Cambodian, Hindi, Hmong, Korean, Lao, Thai, Tongan, Russian, Spanish, and Vietnamese. Access to High-Quality Care by the Numbers 2008 Charity care Medical Financial Assistance awards...29,781 Charitable Health Coverage membership ,274 Medicaid membership ,147 Child Health Insurance Program membership ,489

15 page 28 kp.org/communitybenefit 2008 Community Benefit Report page 29 Spreading Health: Community Health Initiatives across the Country healthy Environments Clark County, WA Portland, OR (3 Sites) Cleveland, OH Imagine Policies that are People-Friendly and Planet-Friendly Santa Rosa, CA Richmond, CA Modesto, CA (6 Sites) H H H HH H H H Port Towns, MD As a health organization, we know that not just health care, but the social, economic, natural, and physical environments that surround us shape our health. We want to support environments that are health promoting. We also want to take accountability for our own environmental footprint and understand the impact that we have on the economy and the environment. Our community health initiatives started four years ago with a focus on Healthy Eating Active Living to address root causes of obesity and related chronic diseases. It has grown and spread to 40 communities across the country. In the past year, our focus broadened to include issues of community economic development, environmental sustainability and neighborhood safety. We understand that to be healthy, families need safe, healthy neighborhoods, schools and workplaces. H Community health initiative sites Joint Initiatives with other funders 21 LiveWell CO (Statewide) Denver, CO Commerce City Park Hill Denver Urban Gardens H Atlanta, GA We also view environmental sustainability as central to health and consistent with our commitment to prevention by: Increasing availability of healthy and sustainably grown food to prevent obesity and chronic diseases. Reducing exposure to toxic chemicals, which can reduce the incidence of asthma, cancer, Parkinson s, and a host of other diseases. Reducing greenhouse gases, which will help prevent the spread of infectious diseases and other health effects of climate change. Community Health Initiatives A Circle of Life and Health Our community health initiatives are a programwide strategy for creating a significant and measurable impact on population health by improving those features of the physical and social environment that can make healthy choices easier, or more difficult. The thematic focus of the program is Healthy Eating Active Living, which targets community food and physical activity environments where individuals live, work, play, and go to school. The long-term goal of this work is to stop the increasing rates of obesity and obesity-related diseases such as diabetes and cardiovascular disease. By building multi-sectoral coalitions and partnerships, engaging community residents, lifting up community assets, and working with community members, we are working to affect policy change and transform community institutions. The earliest cohort of engaged communities is now entering its third full year of implementation. In other regions, communities are now making the transition from an intensive planning stage to implementation. The map below indicates where these collaborative initiatives are taking place. In 2008, we were either the principal sponsor or cosponsor of place-based HEAL initiatives in 40 communities up from 27 in Our partners in jointly funded sites include The California Endowment, the Robert Wood Johnson Foundation, the W.K. Kellogg Foundation, the Centers for Disease Control and Prevention, the Northwest Health Foundation, the Colorado Health Foundation, the Consumer Health Foundation, and the Community Foundation of Greater Atlanta. In addition to these intensive, long-term, place-based collaborative investments, our regions made a wide range of complementary HEAL grants to support more targeted policy and environmental change efforts. In Northern California, 13 local partnership grants supported major innovations in the student food service at San Jose State University and comprehensive school wellness policies in Vacaville Unified School District. In Southern California, we made a significant grant to the California Food Policy Advocates to develop nutrition standards in early childhood settings, an important new venue for policy and practice change.

16 page 30 kp.org/communitybenefit 2008 Community Benefit Report page 31 In Georgia, Kaiser Permanente funds the implementation of student fitness testing and other wellness programs in the DeKalb County School System, the third largest school system in the state. In the Northwest, we sponsored the Metro s Walk There! a guide highlighting 50 walks in the Portland metro area developed in partnership with the Portland, Ore., Metropolitan Transportation Authority and others. Many of these grants include formal evaluation components. In total, we invested $20.1 million in 2008 in community health initiative grants for 1,181 organizations. Our regions also supported community health initiatives with extensive technical assistance, including obesity prevention expertise provided by our physicians and staff. Through site-specific and cross-site evaluation of our more intensive efforts, we are building the evidence for what works and spreading that knowledge far beyond the borders of our communities. Community Health Initiatives by the Numbers The Center for Community Health and Evaluation, the cross-site evaluator for the initiative, recently completed assessment of six Kaiser Permanente sites. They found the following: A total of 139 distinct community change strategies were being implemented strategies ranging from body mass index screenings in community clinics, to creating community gardens that supply local food pantries with fresh fruit and vegetables, to the addition of health elements into city general plans that create bike paths, walking trails, and grocery stores. These elements will promote healthy choices for years to come. These strategies affect more than 182,000 community residents with neighborhood-level interventions and 18,500 with school-level interventions. In subsequent phases of the evaluation, we will be able to identify the percentage of the targeted populations that were actually exposed to the interventions and the impact of those interventions on behavior change. The strategies are working on every level of the socioecological spectrum: 37 percent of these strategies are focused on programs that target individuals and families; 19 percent focused on organizational-practice change; 25 percent focused on environmental changes and/or changes in public policy; and 19 percent focused specifically on community-capacity building. All sectors are engaged in this work, creating the kind of surround sound necessary to have a significant impact on the lives of community members. Fifty-three percent are focused on neighborhoods (i.e., refurbishment of parks, grocery store conversion efforts); 20 percent are focused on schools (i.e., cafeteria reforms); 12 percent are focused on workplaces (i.e., campaigns to promote stairwell use); and 6 percent are targeted on the health sector (i.e., BMI screening efforts). Our community health initiatives started four years ago with a focus on Healthy Eating Active Living to address root causes of obesity and related chronic diseases. It has grown and spread to 40 communities across the country. Community Change: Achievements Building on Denver Urban Gardens Farmers Market and Corner Stores in Denver, COlorado in Modesto, CAlifornia Denver Urban Gardens developed a dense network Through trial and error, Modesto found a way to of 13 small gardens on inner-city lots in the Denver establish a farmers market and supply produce to neighborhoods of Baker, La Alma/Lincoln Park, and neighborhood corner stores at the same time. They Sun Valley. They developed youth and adult garden first trained 40 women to grow backyard produce. programs, healthy cooking demonstrations, and biking/ These neighborhood residents were certified as walking garden tour maps. The goal was initially to producers and a license was obtained to offer a farmers engage residents and use gardens as a tool for building market in the park. While there were some sales of community and strengthening neighborhood plums, chili peppers, peaches, tomatoes, and cherries, connections. They then broadened their scope and getting to scale posed a problem. Some resident created a more integrated approach that now includes growers admitted they weren t able to bring their crops a mobile youth farmers market and a centralized, to the market because their children kept eating their refrigerated storage unit to improve access to fresh produce! Then a new opportunity developed with produce for neighborhood schools and food banks. Heifer International to provide training and growing land to a youth group. The youth now plan to sell plants, flowers, and produce in the farmers market. Supporting Clinical Practice Change Heifer International also provided excess produce at in Santa Rosa, CAlifornia no cost to local neighborhood stores on a delivery Santa Rosa, one of three sites in Northern California, schedule that coincides with most residents pay day has institutionalized BMI screenings in its community to avoid spoilage, providing even greater access to health centers. Supported by advocacy and technical healthy produce for West Modesto residents. assistance provided by our physicians, clinics have adopted routine BMI screenings and questions about Increased Collaboration diet and physical activity for both adults and kids. At in Richmond, CAlifornia one participating clinic, clinicians went a step further, challenging one another to lose weight and improve Prior to the collaborative grant from Kaiser Permanente, their own diets so that they could serve as role models only a few of the 20 current partners in Richmond s to their patients. West County collaborative had worked together before. They also differed in the degree to which obesity prevention was tied to their respective missions. Redevelopment Somehow, their varied but shared interests did the in Commerce City, COlorado trick. Working together on the HEAL Initiative helped The multi-sectoral collaborative in Commerce City the West County collaborative members overcome played a key role in developing a master plan for the previous differences and become a true collaborating Derby neighborhood (the commercial zone of historic organization, in which everyone contributes different Commerce City). Guidelines and zoning rules have strengths and the whole becomes much more than been included that make the area more pedestrian the sum of individual parts. As the former project friendly, thereby promoting physical activity as part of coordinator puts it, It took us a long time to say we. everyday life. The collaborative brought in an expert Now that they are saying we, the group is making on walkable communities, trained students in advocacy, progress on several policy fronts, working to make the and enlisted them in the community change process. city s general plan more health friendly.

17 page 32 kp.org/communitybenefit 2008 Community Benefit Report page 33 This assessment also revealed a number of short-term wins that are having an immediate impact on the communities we serve some of which are described below. Over the long term, the evaluation team will be tracking the impact of these community changes on health behaviors and health status. Meeting Our Communities Where They Are When we launched our community health initiative, HEAL was selected as the thematic focus a recognition of the prevalence of obesity and obesity-related disease in most of our communities, as well as the opportunity to leverage our clinical expertise and organizational commitment to obesity prevention. But obesity is only one of many challenges our communities face. Issues like safety, environmental justice, and economic development are all part of the mix. Often, community residents experience these problems as more immediate and more pressing issues than obesity or other health concerns. At a minimum, these issues compete for community leaders time and attention and, in some cases, they pose challenges to critical HEAL strategies. For instance, an outbreak of gun violence caused one HEAL collaborative to suspend its efforts to promote more use of a neighborhood park and other programs intended to get families to go outside and walk more. Indeed, street violence and perceptions of safety are significant barriers to active living across our collaborative sites. Along with our community partners, we re devoting special attention to the challenge of street violence, which may increase as the recession deepens. Some communities including Richmond, Calif., and Park Hill, Colo., have incorporated explicit violence prevention strategies into their community action plans, partnering with other community groups that focus on violence prevention. For instance, in Park Hill, a partnership between the LiveWell Colorado collaborative and a local nonprofit is providing middle-school children at risk for gang involvement with outdoor experiences and other healthy activities. We re also supporting the Prevention Institute, a national nonprofit organization based in Oakland, Calif., to work with HEAL grantees to identify and develop promising strategies at the nexus of HEAL and violence prevention. These strategies are being shared with a large peer group of community leaders through webinars and face-to-face meetings. We have also begun to address community economic development. All the while, keeping HEAL front and center. For instance, in Port Towns, Md., the community leadership team which includes the local community development corporation and a number of environmental groups has identified economic development and environmental sustainability as core concerns they plan to address as they pursue their HEAL initiative. In Alamosa and Durango, two rural Colorado communities, HEAL collaboratives are connecting local farms to urban consumers. This brings healthy, affordable food to communities with limited access and addresses the need of local farmers for new customers providing a much needed boost to battered farm economies. Safe Routes to School: Helping Kids Get Exercise as Part of Everyday Life A key focus of our work is to make it easier for people to be more physically active in the course of their everyday lives. One example of this is the work being done in our local communities to make sure kids can safely walk or bike to school every day through community programs, traffic safety improvements, and policy change. Safe Routes to School is an international movement that aims to create safe, convenient, and fun opportunities for children to bike or walk to school. While SRTS has been around for the last decade, most efforts have been focused on middle-class, suburban communities. Kaiser Permanente partners with the Safe Routes to School National Partnership, a national advocacy and community journal photovoice: maricela s story Maricela Navarro is an amateur photographer who s also a member of the West County HEAL Collaborative in Richmond, Calif. Because she felt that changes needed to be made in her community, Maricela participated in Photovoice, a communitybased approach to documentary photography that provides people with training in photography and policy advocacy. Maricela felt that liquor stores in her community, especially the one located close to the local school, gave kids, including her own, easy access to junk food and served as a magnet for crime. The liquor store is two blocks from the school, so I wanted something to be done about it being so close. Working with other community partners, Maricela participated in a successful campaign to demolish the liquor store. I got passionate about the pictures that I took and I wanted for those things to be changed in the community, to do something about it, she says. Based upon her experience, Maricela now believes she has the ability to help make changes for the better in her community. She also knows that she s not alone and invites others to get involved. I think the community can be involved, and advocate for things that they want to be changed in the community. Maricela is already thinking about her next project. In the future, I would take pictures of more sites or other things that need to be improved in the community.

18 page 34 kp.org/communitybenefit 2008 Community Benefit Report page 35 technical assistance organization, to develop and enhance SRTS efforts targeting schools in low-income, urban neighborhoods. Over two years, the collaboration among the community coalitions, Kaiser Permanente, and the SRTS national partnership, has brought more than $2 million in SRTS funds to our communities in California and the Mid- Atlantic States. We ve also invested other organizational assets that more fully support SRTS efforts and demonstrate our commitment to improving health beyond the walls of the doctor s office. On October 8, 2008, Safe Routes to School International Walk to School Day drew more than 600 of our physicians and employees, who took steps to create safe walking and bicycling routes to school. In Santa Rosa, Calif., physicians and physical therapists escorted walking school buses, helping approximately 60 children walk to school. In Contra Costa, Marin, and Stanislaus counties in Calif., our employees served as crossing guards and handed out pedometers, Frisbees, and lip balm to walkers. Some employees in Northern California even recruited their friends and neighbors for this event. In South DeKalb County, Ga., the SRTS national partnership teamed up with Kaiser Permanente and our good health mascots, Doc Broc and Nurse Blueberry, at Knollwood Elementary School. Our physicians and employees also wrote letters to local newspapers, urging community members to not only participate in Walk to School Day, but to participate in ongoing SRTS efforts in their local schools as an investment in the overall health of our children. HEAL Convergence Goes Deep and Wide The kind of change we seek cannot be achieved alone. Our community partners are indispensable to making the work happen on the ground. They are the key components for the HEAL movement that is now sweeping the nation. We are working closely with our funding partners in the philanthropic community and in the public sector to provide the financial support, thought leadership and coordination needed to incubate these ideas and realize success. The Healthy Eating Active Living Convergence Partnership is a focal point for this type of collaboration. Co-founded by us in 2006, the Convergence Partnership now includes the Robert Wood Johnson Foundation, the W.K. Kellogg Foundation, The California Endowment, Nemours and The Kresge Foundation. The Centers for Disease Control and Prevention participates in the partnership as a technical advisor. The year 2008 marked a number of major achievements for the partnership. Anticipating significant infrastructure spending as part of the federal stimulus package as well as the Surface Transportation Bill, which authorizes most highway, road, and public transit programs, the Convergence Partnership made strategic investments in activities designed to bring attention to the ability of active transportation to prevent chronic disease as well as to create jobs and reduce greenhouse gas emissions. These included support of the Transportation for America campaign, commissioning papers on the transportation/ health connection and sponsorship of several policymakers and other audiences. The Convergence Partnership also developed an innovations fund to stimulate land use and healthy food retail projects on the part of regional and local funders and launched a new Web site and Web portal ( In addition, regional convergence efforts took firm root in Several of our regions were active participants in these efforts, including California, Colorado, the Northwest, and the Mid-Atlantic States. These regional efforts are central to the convergence strategy of building a network of funders, practitioners, advocates, and policymakers that can articulate and advance a shared model of policy and environmental change. Collaborative Grantmaking to Build a Healthy Future in Anacostia In 2006, Kaiser Permanente provided seed funding for the Summit Health Institute for Research and Education, Inc., to convene a childhood obesity collaborative serving Anacostia, one of Washington D.C. s poorest and most underserved communities. As a result of its initial successes, the coalition was selected in 2008 by the Robert Wood Johnson Foundation to serve as one of its 10 lead Healthy Kids, Healthy Communities sites to implement obesity prevention systems, policies, and environmental strategies. These 10 lead communities will mentor 60 additional sites that will be receiving grants from the Robert Wood Johnson Foundation in Our initial investment has yielded an effective collaboration that is now a national model for delivering healthy eating and active living opportunities to children who are at the highest risk for obesity. Kaiser Permanente is a partner, along with The California Endowment, in three other Robert Wood Johnson Foundation Healthy Kids, Healthy Communities sites, all in California: Oakland, Baldwin Park, and the Central Valley. The rollout and site selection for the Robert Wood Johnson Foundation s Healthy Kids, Healthy Communities program is a testament to what can result when funders coordinate their efforts and leverage each other s investments in order to make better health a reality for all. In the nation s capitol, teachers, students, their families and other supporters take steps to create safer routes to school in their community during International Walk to School Day. Doc Broc dances through Centennial Olympic Park during the March of Dimes WalkAmerica in Atlanta, Ga.

19 page 36 kp.org/communitybenefit 2008 Community Benefit Report page 37 Environmental Stewardship Sustaining the Planet That Sustains Us All At Kaiser Permanente, we recognize that healthy communities and a healthy environment are critical to the health and wellness of every person. We are dedicated to environmental sustainability because it has direct, positive effects on individual and community health. Our environmental roots can be traced to the beginning of the modern environmental movement. In 1963, the environmental crusader Rachel Carson spoke to our doctors in one of her last speeches. Carson warned about the dangers of certain chemicals to human health and to the environment. We were concerned about the environment then, and we re concerned now. More than four decades later, we are working to curb our overall impact on the environment by using safer chemicals, building greener hospitals, reducing waste, and looking at new ways to conserve energy. For our efforts to reduce waste and prevent pollution, we won 12 awards from Practice Greenhealth. Environmental Stewardship Principles, Strategies, Guidelines In 2008, Kaiser Permanente formally adopted environmental stewardship principles, strategies, and guidelines, including specific links to corporate social responsibility principles. We partnered with Boston College s Center for Corporate Citizenship to provide educational materials, training, and support for internal educational efforts. Our collaboration with the center also helped us extend our educational outreach to Global Health and Safety Initiative (see page 40 for more information about the initiative) member organizations, to broaden understanding of corporate social responsibility among leading hospital systems. Environmental Stewardship Guidelines Three specific guidelines were adopted to promote safer chemicals, reduce emissions that cause climate change, and support sustainable food systems: Chemicals We seek to advance an economy where the production and use of chemicals are not harmful for humans as well as for our global environment and its nonhuman inhabitants. Climate Climate change will cause health effects that will directly impact our ability to fulfill our promise of quality, affordable care. We will take practical actions to limit our emissions of greenhouse gases and will help reduce the carbon footprint of the communities we serve. Food We support food systems that are ecologically sound, economically viable, and socially responsible. We strive to provide food that is healthy for people and the environment in which we live. Environmental Stewardship Principles The following principles provide us with a compass for our environmental stewardship work. They are statements of aspiration and intent. These 13 principles communicate our strong commitment to safety, human health, and environmental excellence, and help to describe a path forward: 1. Prevention Focus We will apply a prevention approach to environmental management just as our care delivery system is based on disease prevention, and our safety programs are based on prevention of harm and injuries. 2. Protection of the Biosphere We will make continual progress toward reducing and eliminating the release of substances that may cause environmental damage to the air, water, or the earth and its inhabitants. We will safeguard habitats affected by our operations and will protect open spaces and wilderness, while preserving biodiversity. 3. Sustainable Use of Natural Resources We will make sustainable use of renewable natural resources, such as water, soil, and forests. We will conserve nonrenewable natural resources through efficient use and careful planning. 4. Reduction and Disposal of Wastes We will reduce and, where possible, eliminate waste through source reduction and recycling. All waste will be handled and disposed of through safe and responsible methods. 5. Energy Conservation We will conserve energy and improve the energy efficiency of our internal operations and of the goods and services we provide. We will make efforts to use environmentally safe and sustainable energy sources. 6. Risk Reduction We will strive to minimize environmental, health, and safety risks to our employees, physicians, patients, and the communities in which we operate through safe technologies, facilities, and operating procedures, and by being prepared for emergencies. 7. Transparency We aspire to enhance our accountability and performance by improving the transparency of our environmental impacts. 8. Commitment to Social Equity We will commit ourselves to understanding the implications of the environment on social equity, and undertaking environmental health initiatives that promote social equity and reduce health disparities. For example, we will explore how green programs such as farmers markets, renewable energy, and green job training can help address violence, poor education, hunger, and pollution. 9. Safe Products and Services We will work to reduce and strive to eliminate the use, manufacture, or sale of products and services that cause environmental damage or health and safety hazards. 10. Environmental Restoration We will evaluate environmental impacts of our facilities and strive to avoid actions that endanger health, safety, or the environment. We will work to redress injuries caused to people or the environment. 11. Engage the Public We will regularly seek advice and counsel through dialogue with members, stakeholders and other persons in communities near our facilities. 12. Leadership Commitment We will implement these principles and sustain a process to ensure that executive leadership and governance entities of Kaiser Permanente are informed about pertinent environmental issues and monitor our environmental performance. 13. Audits and Reports We will conduct an annual self-evaluation of our progress in implementing these principles. We will support the timely creation of generally accepted environmental audit procedures. We will report annually on our environmental stewardship to the public.

20 page 38 kp.org/communitybenefit 2008 Community Benefit Report page 39 Modesto Waste Recycling Program We opened our new hospital in Modesto, Calif., in October The new facility is recognized as one of the greenest hospitals in the country. Opening a new hospital involves many challenges, and most of us never think about the enormous amount of packaging material that comes with the delivery of new hospital equipment. To address the issue, a team of facilities experts led innovative actions to minimize the environmental impact of our operations. The team s goal was to deploy equipment into the new hospital with as little impact to the landfill as possible. The materials included cardboard, plastic, pallets, and bubble wrap. One of their biggest challenges was polystyrene (Styrofoam), which comes in large quantities with new equipment. The team identified a recycler 20 miles from the hospital that uses polystyrene to make architectural trim products. They also found a recycler for polyethylene foam, which is the primary packaging material for static-sensitive equipment. When the hospital opened, 97 percent of all packaging materials 37 tons was kept out of the landfill and recycled. Minimizing plastic and other types of waste helps to prevent health effects caused when toxic chemicals leach from landfills into water supplies and soil. Links to Thrive Campaign The poster to the left was hung in our facilities where recycled denim is used for insulation rather than fiberglass, illustrating our commitment to building greener health care facilities. The 2008 Thrive campaign provided an example of one way to link environmental stewardship with organizational strategies and operations. The advertisement below speaks to the need for clean water and clean air as components of good health. community journal Cancer Alley: alice s story Alice Cappel is a Kaiser Permanente member and a new mom. She s also working hard to help preserve and protect the environment, since she has seen firsthand how environmental pollutants can devastate entire towns and the people who live in them. Alice s hometown is Lake Charles, La. I grew up among 23 petrochemical plants and refineries one of the densest concentrations of petrochemical plants in the country. My hometown is right in the middle of Cancer Alley, an area that stretches from Houston to New Orleans, she explains. To help make a difference in the lives of the people in her hometown area, she took a position with a local firm working on environmental law cases. She began her career by interviewing local individuals whose health had been irreparably damaged by environmental pollutants. I met countless workers with cancers and chronic neuropathies. For instance, the chemical plant worker who helped us reveal the dangers of polyvinyl chloride, a type of plastic, was a family man in his 40s who was diagnosed with glioblastoma multiforme. It is a type of brain cancer from which he did not recover. Alice encourages more organizations to follow the example of Kaiser Permanente in helping reduce the use of products made with harmful materials, such as PVC (polyvinyl chloride), a type of plastic that is widely used in many products, from electronics to carpeting. By reducing its environmental impact, Kaiser Permanente is definitely doing the right thing on a lot of fronts, says Alice, who is working toward a better future for her family and for our planet. Our flagship green facility, the Modesto Medical Center, has garnered a lot of positive media attention for its breakthrough environmentally friendly design, and its innovative ideas to improve patient comfort.

21 page 40 kp.org/communitybenefit 2008 Community Benefit Report page 41 Sustainable Purchasing Our environmentally preferred purchasing program is a model in health care. One key success in 2008 involved a new type of patient-controlled analgesia (PCA) pump. We were the first health care organization to contract for the product, which is free from polyvinyl chloride (which creates dioxin pollution when manufactured and incinerated) and free from di(2-ethylhexyl) phthalate (DEHP), a chemical linked to reproductive risks. Annually, we use about 18 miles of tubing with these pumps. The contract also resulted in an overall cost savings from the prior contract, demonstrating our view that environmentally preferred purchasing can support our imperative to keep care affordable. Global Health and Safety Initiative We helped launch the Global Health and Safety Initiative, a sector-wide health care collaboration to accelerate improvements in worker safety, patient safety, and environmental sustainability. The seven major hospital systems that founded the Global Health and Safety Initiative are Kaiser Permanente, Ascension Health, Catholic Healthcare West, Hospital Sisters Health System, MedStar Health, Partners HealthCare, and St. Joseph Health System. The initiative aims to transform the way that health care designs, builds, and operates its facilities, as well as improve the safety and sustainability of products used within those facilities. The initiative is creating a learning community and leveraging the expertise of its partners to support evidence-based improvements. Joining the hospital systems are three nongovernmental organizations that also helped establish the initiative: Health Care Without Harm, Center for Health Design, and Practice Greenhealth. These organizations provide a community voice along with invaluable expertise. The power of the collaboration among these organizations and hospital systems ensures that the health care sector is providing meaningful leadership as the world faces unprecedented environmental, economic, and social crises. Health and Environment by the Numbers 2008 Communities engaged in our community health initiatives...40 Number of community health initiative grantees... 1,181 Residents reached in our first six community health initiative sites ,000 Percentage of our facilities that are now mercury-free...95 Pieces of electronic equipment reused or recycled...74,000 gallons of potable water saved per year by each of our digital X-ray imaging systems, which also eliminate harmful chemicals ,000

22 page 42 kp.org/communitybenefit 2008 Community Benefit Report page 43 developing and Sharing knowledge Sharing Our Insights for the Greater Good At Kaiser Permanente, creating knowledge and translating it into clinical practice is a core aspect of how we give back to our communities. Our unique combination of assets provides a major advantage for clinical and health services research. With a large, stable membership that is representative of diverse populations, and care documented in a state-of-the-art electronic health record, our highly experienced investigators have a unique toolset at hand. Together, these assets facilitate in-depth analyses that create valuable insights and knowledge that can be quickly translated into practice to benefit our members and communities. Developing Knowledge Operating in every region, our research centers generate important findings that contribute to the advancement of the prevention and treatment of a variety of health concerns. Collectively, our body of research illustrates our commitment to tackling major health problems and sharing that knowledge with the field. Last year, our investigators were engaged in more than 3,150 research and evaluation studies and published more than 700 articles in peer-reviewed journals generated from study findings. The studies were featured in prestigious publications such as The New England Journal of Medicine, The Journal of the American Medical Association, American Journal of Public Health, Annals of Internal Medicine, Obstetrics & Gynecology and many other general and specialized journals. Among our many research findings in 2008 were studies documenting a link between mid-life abdominal fat and the risk of dementia; a correlation between food diaries and weight loss; the effects of stress on aging; and a possible link between red wine consumption and the incidence of lung cancer. These studies, along with the following projects, are examples of how our research teams are making a difference in the lives of people around the world: Diabetes Prevention and Treatment: Our Southern California researchers found the incidence of diabetes before motherhood has more than doubled among teenage and adult women in the last six years. Another study by our researchers in the Northwest found that those who lose weight soon after a diagnosis of type 2 diabetes are more likely to maintain control over blood pressure and blood sugar. We also have one of the country s most comprehensive registries of patients diagnosed with diabetes, which helps clinicians better serve patients, and patients better manage their disease. Obesity, Asthma and Osteoporosis at our Center for Health Research: Researchers in the Northwest, Georgia, and Hawaii published several key studies in Among their findings was that keeping a food diary doubles weight loss and that obese people with asthma have a much greater risk of hospitalization. In collaboration with the University of Alabama at Birmingham research team, investigators are currently conducting a randomized trial study to test the effect of simple interventions to improve health care among women at least 65 years of age who are at high risk for osteoporosis. Coronary Artery Risk Development Study in Young Adults: Investigators at the Northern California Division of Research demonstrated that healthy lifestyle behaviors in young adulthood protect against heart disease. The study found that participants who reported five unhealthy lifestyle practices at the baseline exam such as smoking, high alcohol intake, unhealthy diet, low physical activity, and being overweight had nearly five times greater chance of developing coronary artery calcification 15 years later than did participants who reported none of these behaviors. Human Immunodeficiency Virus Initiative: Our investigators studied a wide range of issues, from the cost of HIV medications and HIV testing to HIVrelated malignancies, quality performance measures, HIV multidisciplinary care, cardiovascular disease in HIV-infected patients, and toxicities of HIV therapy. Cancer: We expanded collaborations with other research partners to participate in large-scale clinical trials. Southern California s Department of Research and Evaluation was honored by the American Society of Clinical Oncology for its clinical trials research, and our Northern California Oncology Clinical Trials program became a full member of the Southwest Oncology Group, one of the largest cancer clinical trials cooperative groups in the United States. Translating Research into Practice In 2008, we also expanded collaborations with major public health agencies, academic institutions, health foundations, and other research partners to launch large-scale studies. We are partnering with the National Heart, Lung and Blood Institute, part of the National Institutes of Health, on one of the largest and longest running weight-loss maintenance trials ever conducted. We go beyond conducting research to ensure that our communities and the field of health care benefit from the findings. It has long been our practice to actively disseminate what we learn by partnering with influential professional and scientific organizations and by translating our knowledge for a variety of audiences, including health care and public health practitioners, policymakers, and the public at large. We have expanded our partnerships with professional, scientific, and academic organizations to actively translate research into practice.

23 page 44 kp.org/communitybenefit 2008 Community Benefit Report page 45 Evolution of Gene Environment Research Program Our Research Program on Genes, Environment, and Health was launched in 2007, with the goal to identify genetic and environmental factors that affect human health and to use that knowledge to improve health care for our members and the general public. It involves collecting information from Northern California members who consent to participate anonymously in the program from three sources: participant surveys regarding lifestyle, family history, and other factors; participants electronic health records; and genetic information from saliva and/or blood samples that the participants contribute. All of this information is de-identified a careful process that ensures protection of the confidentiality of participant information and is then entered into a databank, which can be linked as needed with other databases, with detailed environmental information on air quality, exposure to toxins, and even aspects of the social and built environment, such as neighborhoods that lack sidewalks and safe parks. Research utilizing the RPGEH data could lead to entirely new ways of diagnosing, treating, and even preventing major diseases like cancer, heart disease, asthma, diabetes, and mental health disorders. RPGEH Receives External Support In December 2008, the Robert Wood Johnson Foundation awarded $8.5 million to the RPGEH, reflecting the interest the program has attracted outside Kaiser Permanente. Prior to 2008, the RPGEH was funded by Kaiser Permanente and also received grants totaling $4.7 million from the Wayne and Gladys Valley Foundation and The Ellison Medical Foundation. Over the next four to five years, the RPGEH aims to collect information and saliva or blood samples from 500,000 consenting Kaiser Permanente members in Northern California. The size, diversity, and comprehensiveness of the resulting resource should enable researchers to identify the subtle effects of interacting environmental and genetic factors in common and less common health conditions. Beginning Collection of DNA Samples In 2008, the RPGEH entered the second phase of developing the databank. After approximately 400,000 members responded to the initial RPGEH health and lifestyle survey, the project began collecting saliva samples from participants for DNA samples. By year-end, close to 100,000 consent forms and approximately 40,000 saliva samples had been collected by mail. The program will continue to contact survey respondents and other Kaiser Permanente members in Northern California to obtain consent forms and saliva samples, with an expectation of collecting more than 100,000 samples by the end of Research Already Underway Together with the University of California, San Francisco, RPGEH researchers received $2.3 million in grant funds from the National Cancer Institute to study prostate cancer in African Americans. Prostate cancer is the most common non-skin cancer in the United States and affects one in six men, and it disproportionately affects African Americans. The National Institute of Mental Health has awarded a five-year, $12.7 million grant to the RPGEH and UCSF Institute for Human Genetics for a multiethnic study of the genetic factors that may determine risk for bipolar disorder, which affects about 1 to 2 percent of the population. Evidence from prior research strongly suggests that bipolar disorder has a genetic basis. The research provides an outstanding opportunity to enhance understanding of the causes of the disorder and may eventually lead to more effective treatment options for individual patients. With our systemwide conversion to Kaiser Permanente HealthConnect, the largest civilian electronic health record system in the world, we are rapidly accumulating data that will provide clinicians and researchers detailed information about the characteristics of the patients we serve, the care they receive, and the health outcomes they experience. By assessing and improving the quality, consistency, and accessibility of our integrated clinical data resources, we are making it easier for clinicians to learn from each other and enhance the quality and affordability of the care we deliver. Our research informs the entire field of medicine and contributes to a growing body of science around the origins, factors, and treatment of chronic disease. It also contributes to improvement of Kaiser Permanente s care and service delivery. Last year, we published results of a pilot that substantially improved the heart attack survival rate for our members in Colorado. An innovative program links Alameda County and contra costa county poverty rates SAN FRANCISCO berkeley oakland % below poverty by census tract 0% 2.5 % 2.51% 5% 10.1% 20% 20.1% 30% hayward Concord contra costa county fremont alameda county map not to scale æ N coronary artery disease patients and teams of pharmacists, nurses, primary care doctors, and cardiologists with an electronic health record and advanced clinical care registry. These teams were able to reduce coronary artery disease deaths by 73 percent. Now, we are spreading this practice and testing the same technologies and processes to tackle other chronic conditions throughout our delivery system. Several years ago, we designed the Archimedes Model, a full-scale simulation model of human physiology, diseases, behaviors, interventions, and health care systems that predicts risk factors and treatment benefits. Doctors will soon be able to use a tool derived from Archimedes to help develop customized treatment plans for their patients. We began to use geographic information system technology to help understand how social and environmental determinants of health like poverty affect the prevalence of diseases like diabetes in our communities. all members alameda county and contra costa county diabetes prevalence rates by census tract SAN FRANCISCO 0% 3 % 3.01% 5% berkeley oakland hayward Concord contra costa county fremont all members rate of DIABETES cases by census tract 6.01% 7% 7.01% 8% alameda county map not to scale æ N 5.01% 10% 30.1% 59% 5.01% 6% 8.01% 10.1%

24 page 46 kp.org/communitybenefit 2008 Community Benefit Report page 47 KFRI: Celebrating 50 Years of Innovation Through Research During 2008, the Kaiser Foundation Research Institute celebrated its 50th anniversary. Since 1958, KFRI investigators have worked to improve the health of future generations through research. The anniversary celebration highlighted some of the key milestones in the early years of the program: In the 1940s, our pioneering chief of medicine, Morris Collen, MD, set the standard for healing pneumonia victims in a pre-penicillin world. At that time, Dr. Collen also began the project that ultimately laid the foundation for KP HealthConnect. Dr. Collen later was the founding director of Northern California s Division of Research. Educating the Health Care Partners of the Future Our first and largest graduate medical education program began more than 60 years ago in Oakland, Calif. Last year, we invested approximately $74 million to educate health care professionals across our regions. We trained approximately 2,607 residents and interns, and made significant investments to train nurses, pharmacists, and other allied health professionals. In San Francisco, one of our residency programs offers a four-year program that combines internal medicine, public health, and preventive medicine. This is one of only six such combined programs in the United States. The residency program is a collaboration with the University of California, San Francisco Division of Preventive Medicine and Public Health and the University of California, Berkeley School of Public Health. A similar combined residency program in Oakland offers residents involvement with our Division of Research to increase skill and competencies in core public health areas, including biostatistics, epidemiology, and health policy management. including those headed to careers in the safety net, access to expansive course material not currently offered in their customary clinical education. In addition, we supported a number of other educational programs for health professionals: Nurse Practitioner and Non-MD Staff Trained In 2008, in response to the regional and national shortage of allied health care professionals, we provided on-site training opportunities to more than 5,400 nurses, radiology and sonography technicians, and other allied health care professionals. Pharmacy Postgraduate Residency Program in California There is a serious national pharmacist shortage, including a greater shortage of pharmacists trained and qualified to manage high-risk drug therapies for high-risk patients. In 2008, Kaiser Permanente community benefit supported 48 nationally accredited pharmacist postgraduate residency students. In the mid-1940s, Herman Kabat, MD, PhD, called boy wonder by TIME magazine in 1946, was asked by Henry Kaiser to start the Kaiser-Kabat Institute in Washington, DC, to help persons with multiple sclerosis like Kaiser s son, Henry Kaiser Jr. Dr. Kabat s legacy lives on at our rehabilitation center in Vallejo, Calif., and in the techniques used worldwide to treat victims of neuromuscular disabilities. The collective contributions of more than 115 researchers in our research centers reflect the ways in which our scientific findings contribute to evidence-based knowledge that improves the lives of our members, the communities we serve, and the medical field as a whole. Henry Kaiser and Herman Kabat, MD, PhD, with a patient at the Kabat-Kaiser Institute in Vallejo, Calif. The Kabat-Kaiser Institute in Washington, D.C. We re also pleased to be one of the inaugural financial supporters of the Institute for Healthcare Improvement s Open School for Health Professions. Our three-year, $750,000 commitment supported the development of a virtual school. The first of its kind, the Open School introduces health professional students to the tools and skill sets required to be leaders in quality improvement in their future careers. Featuring world-renowned experts in performance improvement, patient safety, and quality measurement, the online school provides a curriculum that introduces students to the science of quality improvement, and also supports peer-to-peer networking through local chapters and mentoring arrangements. The school will allow thousands of health professional students, Combining Medical Training and Care for the Uninsured and Underserved in California A number of our training and education programs offer a unique community service rotation through community clinics to support safety net providers. They also deliver care for vulnerable populations and provide training for our graduates in providing culturally responsive and competent care for diverse populations. Graduate medical education programs in Northern and Southern California rotate residents through local community health centers and clinics, providing comprehensive care for families, women s health evaluations, general gynecological care, and pediatric care.

25 page 48 kp.org/communitybenefit 2008 Community Benefit Report page 49 community journal Institute for Health Policy Making It a Practice to Improve Health Care The Kaiser Permanente Institute for Health Policy provides a focus and resources for us to help shape the nation s health policy agenda. Working in collaboration with foundations, policy institutes, research programs, federal and state policymakers, and other stakeholders, the institute seeks to develop unbiased information about health policy issues to increase understanding and help provide solutions. In 2008, the institute sponsored or cosponsored a variety of policy roundtables on a range of subjects that leverage our expertise, experience, and interests, including: Hospital/Physician Collaboration Patient-Centered Care and Health Reform California Health Care Reform Publications IHP produced or commissioned policy briefs and background papers on the following subjects in 2008: Kaiser Permanente HealthConnect : Lessons From the Research Literature Hospital-Physician Collaboration: Landscape of Economic Integration and Impact on Clinical Integration Physician Organization in Relation to Quality and Efficiency of Care: A Synthesis of Recent Literature Preparing for the Personal Health Record Whether they are addressing health reform, patient safety, or Medicare solvency, the success of policy proposals is profoundly influenced by their coverage in the media. Last year, IHP implemented a new project developed to engage both veteran and future journalists in improving coverage of complex health policy issues. Making a Personal Contribution Toward a Better World At Kaiser Permanente, we recognize that our greatest strength is our people. We are proud to have dedicated, generous physicians and employees who go beyond the call of duty to have a positive impact on the community. Volunteerism and community service by employees, physicians, and their friends and families can make measurable impacts on the health of our communities. Every year, our employees nationwide are encouraged to celebrate the Martin Luther King Jr. holiday honoring Dr. King s legacy by spending the day providing service to their communities dubbed a day on rather than a day off. In 2008, nearly 5,000 employees and physicians at 79 sites across all eight regions dedicated their time and talent as part of Kaiser Permanente s day of community service. Last year, as part of our ongoing commitment to help rebuild communities devastated by Hurricanes Katrina and Rita, we organized a group of 60 employee and physician volunteers to assist in recovery and rebuilding efforts in the Gulf Coast. Volunteers from each of our regions focused on assisting people in the New Orleans, La., and Biloxi, Miss., areas. The volunteers worked on various recovery projects, including painting murals, erecting a greenhouse at a local high school; homes rehabilitation; and environmental restoration projects. The two weeks of service in the Gulf Coast area was the longest corporate commitment that the Points of Light Institute and the HandsOn Network have coordinated since Hurricane Katrina hit the region in August We continue to honor the pledge we made Institute for healthcare improvement SCHOLAR: IMAN s story Iman Nazeeri-Simmons, MPH, associate administrator of Quality and Patient Safety at San Francisco General Hospital, the city s public hospital and trauma center, is someone who knows from personal experience that one person can make a difference. Through the support of Kaiser Permanente, Iman attended the Institute for Healthcare Improvement training on becoming a patient safety officer. It involved a one-week intensive course in Cambridge, Mass., and gave her the tools she needed to affect change at her institution to provide consistently high-quality care for patients. The IHI training was close to career altering and an inspiration around the topic of patient safety, Iman says. After I got back, I began to ask, How do I take this information to the 5,000 colleagues who work in my hospital facility? Three months after her return from the patient safety officer training, she had assembled a multidisciplinary group of experts to create a training curriculum. One project the team initiated was a structured implementation of care processes to help reduce the risk of pneumonia for all patients on specialized ventilators. Specifically, the standards of care included elevating the head of the bed and oral care more than once per day. In addition to these basic care processes, the quality team found that the administration of antibiotics also played a key role in determining patient outcomes. The team s analysis showed that some clinical departments needed more support with infectious disease experts and clinical pharmacists to appropriately diagnose and treat a patient who might require antibiotics. By addressing these issues, the team successfully implemented optimal care to patients on a ventilator and decreased the potential overuse of antibiotics. I am so grateful to Kaiser Permanente. Because of what we ve learned, we ve seen changes in our care processes, and we ve seen a mindset shift because the nurses are feeling ownership in care outcomes that will lead to better patient outcomes, Iman says. You can make improvements in complicated systems.

26 page 50 kp.org/communitybenefit 2008 Community Benefit Report page 51 then to help with the long-term recovery and rebuilding efforts needed to help people affected by the storms. In response to the enthusiasm of our employees and physicians to volunteer, we re developing a new volunteer Web site, with rollout expected in The KP Cares site was designed to facilitate physician and employee engagement in meaningful and effective community service. The site will allow administrators to identify volunteers who have specific clinical and other skills in times of need, including disaster relief, as well as providing ongoing opportunities to engage in local community service projects. Educational Theatre Program Our Educational Theatre Program is a potent strategy for disseminating our experience and clinically honed prevention messages to students, families, and their broader communities. ETP is free of charge to schools and the general community. Using live theatre, music, comedy, and drama, ETP engages kids, teens, and adults on a wide range of subjects, including: healthy eating, physical activity, conflict resolution, peer pressure, HIV/AIDS, tobacco use, and dealing with grief and loss. The program s goal is to inspire individuals and communities to make healthy choices. Kaiser Permanente International Supporting Quality Care Around the World Kaiser Permanente International brings our knowledge and experience to governments, health care providers, health plans, and other institutions throughout the world that are striving to improve their health care systems. In 2008, we shared our knowledge and experience with hundreds of health care leaders in more than 20 countries. We held two Integration and Innovation in Health Care programs in the San Francisco Bay Area, This unique combination of responsive and proactive components is an innovative approach to community service management. We look forward to leveraging these tools in combination with a workforce of 167,000 employees and physicians eager to act on the myriad of volunteer opportunities available. In 2008, we extended ETP to every Kaiser Permanente region. Performances and workshops reached 557,426 students and 121,061 adults in schools nationwide. ETP has become increasingly integrated with our community health initiatives effort to promote Health Eating Active Living. Thomas Barber, MD, associate physician-in-chief at our Oakland Medical Center in Oakland, Calif., shows international visitors how we use information technology to improve integrated care delivery during one of Kaiser Permanente International s Integration and Innovation in Health Care conferences. attracting about 50 leaders each. For the first time, we also conducted a Spanish-language program for a group of hospital leaders from Catalonia, Spain visiting Southern California. Last year, as part of our ongoing commitment to help rebuild communities devastated by Hurricanes Katrina and Rita, we organized a group of 60 employee and physician volunteers to assist in recovery and rebuilding efforts in the Gulf Coast. Our Educational Theatre Program uses live theatre, music, comedy, and drama to engage kids, teens, and adults on subjects like healthy eating and physical activity. Sharing Knowledge by the Numbers 2008 Published research studies Research and evaluation studies underway... 3,150 Educational Theatre Program performances... 2,631 Children and adults reached through our Educational Theatre Program ,487 Residents and interns trained... 2,607 Nurse practitioner and other non-md staff trained... 5,419

27 page 52 kp.org/communitybenefit 2008 Community Benefit Report page 53 The 2008 David Lawrence Community Service Awards The David Lawrence Community Service Awards recognize individuals and groups throughout our regions who champion outstanding community service and initiatives that demonstrate their extraordinary efforts to improve the health of our communities. The award includes gifting $10,000 to the nonprofit organization of each winner s choice. In 2008, more than 270 nominations were submitted, more than doubling the submissions in The winners were selected by a committee of the Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals board of directors. Six individuals and four groups received the awards. Group Awardees Individual Awardees Jay Colas, RN Northern California Region: A nurse at our Walnut Creek facility, Mr. Colas organized and increased employee involvement in the Every 15 Minutes program designed to reduce the incidence of teenage drinking and driving behavior. Jennifer Choy, MD Northern California Region: A strong health care advocate in the Asian community in Sacramento, Dr. Choy serves as one of three directors, and the physician lead for the Prism Project, a three-year plan to reduce domestic violence and address community mental health concerns. She has led domestic violence education and training for primary-care doctors and presented legislative testimony to raise government funds. Stuart Oken, MD Northwest Region: For over 15 years, Dr. Oken has been a volunteer member of the governing board of The Foundation for Medical Excellence and FolkTime, which provides community contacts and other needs to the mentally ill in Oregon. Dedicated to improving the health of the mentally ill, he has served as a volunteer physician advisor for more than five years at our Center for Health Research in Portland. Terri Richardson, MD Colorado Region: Dr. Richardson serves as the clinical director for the Colorado African-American Center of Excellence, an organization she founded that identifies and eliminates health care disparities within the African-American community, with a current focus on cardiovascular health. Don t Buy the Lie Tobacco Use Prevention Program Northern California Region: For the past 15 years, our Health Education Department in Sacramento has developed and implemented the Don t Buy the Lie Tobacco Use Prevention Program a comprehensive, multimedia program to counter the pro-tobacco influences that face youth today. Raymond Kay Community Clinic Fellowship Southern California Region: This innovative program is designed for nurse practitioners and physician assistants to practice for one to two years in community-based safety net clinics, with salary and benefits paid by Kaiser Permanente. David E. Harmon, MD Southern California Region: Safety net clinic volunteer, medical director, and champion for the chronically homeless and permanently disabled population of Kern County, Dr. Harmon is a volunteer medical director at Bakersfield Homeless Shelter. A veteran volunteer of 18 years, Dr. Harmon sees about 500 shelter patients a year and has recruited others to join his effort. Philip J. Tuso, MD Southern California Region: Dr. Tuso established the Foundation to Improve Renal Nutrition. Its mission is to help people with kidney disease live longer and healthier lives through proper nutrition and education. Dr. Tuso has expanded this work, starting a local free clinic through a crosssector effort by Antelope Valley Partners for Health, and even bringing dialysis to a clinic in Ethiopia. Orange County Family Medicine Residency Program Southern California Region: Based at the Tustin-Santa Ana Medical Office, this program provides high-quality, culturally competent care by assisting underserved individuals in the surrounding Latino community. Head and Neck Cancer Group (top photo) The Urology Prostate Cancer Group (bottom photo) Southern California Region: These two dynamic groups in Fontana bring the early detection and prevention of prostate, and head and neck cancer to the forefront of public awareness, especially in the underserved, lowincome communities they serve.

28 page 54 kp.org/communitybenefit 2008 Community Benefit Report page 55 Looking ahead 2009: Meeting the Challenges. Maximizing the Opportunties. As the economy continues its downward spiral, we re witnessing firsthand its impact on our friends, our families, and our community. Our immediate challenge is to help those who have lost their jobs and health coverage, and to support our fragile community health programs. More broadly, we need to promote health reform now more than ever. Helping Our Communities Adjust to Economic Uncertainty We want members of our communities to emerge from this economic crisis in good health. In 2009, we need to ensure that our Medicaid, Children s Health Insurance Program, Charitable Health Coverage, and Medical Financial Assistance programs are available to our members and those who have lost their jobs and their health coverage. We ll help them understand their options and find ways to gain continued access to health care if they lose their employer-based coverage. Assuring access to high-quality health care for everyone is more than any single organization can accomplish alone. The decline in state revenues will mean cuts in programs at the same time rising unemployment also causes Medicaid and CHIP enrollment to rise and the number of uninsured to grow. That s why our safety net partnerships, grants to community-based organizations, and our Healthy Eating Active Living programs will continue to support important community-based efforts for individuals and organizations hardest hit by the economy. Providing a Medical Home As more people lose their jobs and health coverage, resources like Medicaid and CHIP have become more important than ever before. We will be evaluating the results we ve received from the five regions that tested our Medicaid care management pilot for broader implementation. Also in 2009, the Georgia Region will begin to provide specialty care to people enrolled in feefor-service Medicaid and the Mid-Atlantic States and Ohio regions will provide primary care services for local Medicaid plans. If the states can find the required matching funds, federal reauthorization of the CHIP program could result in a major expansion of the program for children of low-income families. If the expansion happens, we ll transition those who are newly eligible for CHIP out of our own charitable coverage programs in order to meet the needs of others who are uninsured. We will also work with community organizations to help match people with other benefits they are eligible for food, energy, housing, and health care assistance. As national health reform is articulated and, hopefully, enacted and phased in, we will continue to assess what gaps remain in access to care, and how our Charitable Health Coverage and other programs can meet these needs. Partnering With Our Communities Through our safety net partnerships, we will continue to support health care for low-income and vulnerable individuals who rely on the patchwork of government and community-supported programs. Because of the current economic crisis, safety net resources are overwhelmed by the needs of the newly uninsured. That s why we ll continue to support our partners who share our conviction that patients who receive care at community clinics, public hospitals, and local health departments should have the same expectations as everyone else safe, efficient, patientcentered, culturally competent, and comprehensive health care provided by top-notch physicians and nurses. These are the elements of a health care system we are trying to build and support in our communities.

29 page 56 kp.org/communitybenefit 2008 Community Benefit Report page 57 Balancing Basic Needs With Progress These days, communities are struggling to maintain vital services as their needs swell. We re retargeting our grant-making efforts to help address basic needs like food security, and to support fragile community health infrastructures. As private and public funding for community-based organizations decreases, demands for our support will grow. We have already seen corporate and foundation funding drop as the economy worsened. Now we are seeing public funding shrink as the economic crisis cascades to state and local government budgets. In 2009, we anticipate that the recession could undermine the Healthy Eating Active Living agenda we have been pursuing in our communities. The allure of inexpensive fast food makes it more difficult to promote healthy eating. Concerns about safety and security undercut programs designed to get people out of their homes so that they can start walking, biking, and exercising in their communities. Our HEAL community coalitions are adjusting their long-term environmental and policy-change goals to address the increased immediate needs for essential human services. The economy is causing reductions in key public health programs and threatens the financial security of our community partners. It is also putting significant strain on the lives of community residents as seen in falling rates of health care coverage, increased demand for emergency food assistance, and pressure on the shelter system. Yet, these challenging times also present new opportunities. The American Recovery and Reinvestment Act of 2009 and some state and local investments include significant funding for prevention programs and infrastructure projects that promote bicycling, walking, and eating healthy food. Shaping the Health of Our Communities and Our Country There are other ways we can have real impact on the health of our communities. These include training health care workers, sharing our research findings, eliminating health disparities, promoting environmental health and sustainability in health care, and engaging in the movement for national health care reform. Strengthening Tomorrow s Health Care Workforce Training the health care workers of the future is integral to how we translate our experience into health policy and practice. But the looming shortages of primary care physicians and public health professionals have become obstacles in this effort. We have been developing programs with and providing funding for two institutions to specifically address these shortages. We look forward to launching these programs in 2009 and will be evaluating their effectiveness. The School of Public Health at University of California, Berkeley will be expanding its entering class by 20 students, who will be recruited from underserved communities. Once this group of 20 students graduates, they will be placed in health departments and other public health organizations. The University of California, Los Angeles David Geffen School of Medicine will help international, bilingual medical school graduates living in the United States to pass medical licensure exams so that they too can work in our underserved communities. Leveraging and Expanding Our Research Capabilities Research conducted at Kaiser Permanente also helps shape the way in which the field practices medicine, and informs people everywhere about how to improve their health. Many look to us to address the critical health questions. As one of the nation s largest research institutions, we offer a unique combination of assets an integrated health care system with a large, stable, and diverse membership and a state-of-the-art electronic health record. These make us a natural resource for the comparative effectiveness research being called for in today s health care reform debate. In 2009, we will be expanding our capacity to conduct comparative effectiveness and drug safety research, growing our participation in clinical trials, addressing critical operational questions, and enhancing collaboration among our research departments and analysts. Alleviating Health Disparities We are committed to identifying, measuring, and eliminating disparities in health and health care. One way we accomplish this is to provide equitable access and care to our members. In 2009, we will focus on building the base of information and the metrics to assess the degree to which race, ethnicity, and language account for disparities in the health of our members. That knowledge will be the foundation for an action agenda to address and eliminate those disparities, in our delivery system and beyond. Creating Health in the Physical and Natural Environment We are dedicated to environmental sustainability and social equity, as we believe these have direct, positive effects on individual and community health. The national focus on restoring the economy through green jobs gives us and our community partners a chance to champion a new model of sustainable thinking the health of our people, our planet, and our economies can be aligned. In 2009, we plan to track and report our greenhouse gas emissions, develop public education programs, and enhance waste minimization programs. We ll also engage with public and industry stakeholders on topics like green chemistry, sustainable agriculture, and climate change. Reducing the health risks associated with environmental factors, such as reducing exposures to harmful chemicals, will help lead the way toward safer hospitals and healthier communities. In doing so, we can exemplify how large organizations can prevent environmental harm that has direct health consequences. We will also promote collaboration within the health care sector through the Global Health and Safety Initiative. This initiative aims to accelerate performance improvement in worker safety, patient safety, and environmental sustainability. We play a leadership role within GHSI and will help ensure the success of this collaboration of major health systems and nongovernmental organizations. Being a Catalyst for Health Reform National health reform is a possibility in There is great hope and momentum, and we are participating actively in helping to fashion it. We believe universal coverage is critical, but so is reform of the delivery system and the prevailing fee-for-service payment system. We must also develop the body of evidence for what is costeffective care and expand comparative effectiveness research. At the same time, we must strengthen the ways our communities, schools, workplaces, and public policies can help keep us healthy. Prevention is critical. Our community benefit work offers a real resource to policymakers designing national health reform: our programs for the uninsured, our partnership with the safety net to improve care and eliminate disparities, our work with communities to develop healthier environments, and our research on what truly works to heal patients and to keep people healthy. We are committed to using our assets for concrete, measurable, and visible improvements in the health of our communities and the nation.