In 1998, KP CO started the Chronic Care Coordination program to target patients with chronic conditions, but over the years the program's focus became diffuse and lacked clear outcome metrics.  So in 2003, KP Colorado began a redesign of the program with the establishment of an advisory committee comprised of clinical care coordinators, nurses, and the director of hospital services.  The committee conducted an evidence-based review of the literature and redesigned the Chronic Care Coordination program based on their review.

The new model was implemented in every facility in the Denver metropolitan region within one year.  To date, approximately, 9,000 patients per year have been treated through the Chronic Care Coordination program.

KP Colorado recruits RNs with experience in chronic disease management or geriatrics.

KP trains newly hired RNs in transition care and communication and resources at KP and in the community.  The RNs already on the team do most of the training, along with HR. Nurses are trained in the management of the most common chronic diseases such as COPD and diabetes.  Utilizing protocols approved in the region, the nurses can then provide disease specific follow up care.  New nurses are trained in the use of the electronic medical record and the use of consistent and complete documentation.

In addition, the nurses are trained in several areas of behavioral/change management including motivational interviewing and crucial conversations.  Ability to communicate is vital to the success of this role since so much of the care is telephonic.

Patients are traditionally referred to Chronic Care Coordination (CCC) after an acute care episode.  The hospital or skilled nursing facility discharge note is forwarded electronically to the CCC coordinator, who reviews the note within 24-48 hours and will call the patient to do conduct an initial guideline-based assessment to see whether CCC makes sense for that patient.  Currently the CCC model focuses on medical discharges and do not provide follow up care for surgical procedures.

In addition, patients are referred to the program by KP physicians and clinical pharmacists who round at skilled nursing facilities.

Currently Kaiser Permanente is working on replicating this work in other regions.  In 2007, a training session was held with representatives from all Kaiser regions to train other managers in the implementation of this program.

The Chronic Care Coordination programs works well in an organization that has good integration between hospitals, skilled nursing facilities and physician clinics.  Organizations considering the adoption of this model should make sure they have systems in place to help identify and manage patient care and information across settings.