The Chronic Care team consists of 17 specially-trained RNs (nine of whom are full time) and two Licensed Clinical Social Workers (LCSW). Together, the RNs and LCSWs collaborate with clinical pharmacists, geriatricians and primary care doctors. The partnership with the pharmacy in particular is key to a smooth transition to a higher quality of care. The CCC staff work out of KP primary care clinics, which enables collaboration with primary care providers and relevant ancillary staff (e.g. nutritionist/dietician, diabetes manager).
The team is available on-call and by appointment. Every CCC-followed patient receives at least one outreach call within 24-48 hours of discharge during the business week, which is crucial to effective patient support.
Right now, CCC has one regional manager, a director, and most facilities have only one RN CCC Coordinator, although some of the larger facilities have two. Moving forward, CCC has established a lead care coordinator in order to decrease variability in clinical contacts and to help patients get to the most appropriate caregiver.
Services provided to CCC patients include medication reconciliation, review of discharge plans and recommendations, education and support, and coordination of services (e.g. helping schedule appointments). Over 90 percent of the care is provided telephonically.
Within 24 hours of a patient referral, the CCC coordinator calls the patient to conduct an initial guideline-based assessment to determine if CCC makes sense for that patient. Once the RN coordinator determines that the patient qualifies for the program, the patient is placed into one of four levels of service.
- Referral. These patients only require initial assistance transitioning into an area of care within Kaiser Permanente. They may require a consult from a specialty department, or home health services or some level of care outside of primary care. The chronic care coordinator consults with providers on who best can serve these patients needs within the system.
- Consultation. These patients only require one to two days of help. Nurses help these patients with implementation of discharge plans, coordination of care needed, and education on areas of care they may not understand. The CCC RN may also reconcile medications for these patients.
- Short term management. For these patients, CCC staff are committed to patient self efficacy and working with the patient to meet self care goals. These patients receive approximately one nurse call per week and remain in the program up to two months. The majority of patients are at this level less than 30 days. During this time, the patient will receive medication reconciliation and education specific to her or his care plan. In addition, CCC staff will make sure that all necessary durable medical equipment and supplies are provided to the patient and will review the patient for home safety and ability to care for self.
- Long term management. Long-term patients receive all the same care and follow up as short term but they are generally more complex and require a longer period of intervention. These patients receive nurse phone calls initially once a week and then once a month as appropriate. Approximately 10 to 15 percent of patients are at this level, and they typically receive four to six months of care management, although some patients remain in the program for years. Many long-term patients will transition into hospice, assisted living, or palliative care.
A critical component of the Chronic Care Coordination program is seamless communication between providers and the patient, which takes place entirely through a shared electronic medical record. Information among all the care providers working with a patient is shared through the electronic medical record. As a result, the CCC nurses start with a good understanding of a patient’s needs and can update the EMR with relevant information from their interactions with patients. The EMR also ensures that if the patient comes into contact with some other provider at a different point of care, all providers will be working with the same information including actual current medications and diagnoses.