Chronic Care Coordination receives Vohs Awards
They have been called angels, and are considered the concierge of patient care. The Chronic Care Coordination (CCC) program in Colorado is an example of excellence that has been recognized by being part of a multidisciplinary program winning the Vohs Award in 2006.
Imagine that you or a loved one is in long-term care, such as a skilled nursing facility (SNF). Care is constantly provided and monitored for you. When the time comes to be transferred, either to another facility or a home, many tasks and routines are carefully explained to you. You arrive at your destination, and then you suddenly have a completely different life to deal with. Appointments with physical therapy, medical appointments, and medicine regimes become the new reality, and you are usually on your own. How to organize all this into a new life and stay on top of managing your complex medical condition?
This is how the CCC program came into being. KP CO 's nursing leaders targeted this patient segment as well as patients with multiple chronic conditions and high utilization for study and improvement, and supported and promoted the resulting successful findings and innovations. In 1988, KP CO started the Chronic Care Coordination program to target these patients. Over the years the program's focus became diffuse and without clear outcome metrics, so in the Spring 2003, individuals from KP CO's Nursing Services, Clinical Research Unit, Primary Care medical group and health plan leaders, Continuing Care, and Chronic Care Coordinators met to redefine and focus the program On key evidence and outcome metrics.
The Chronic Care team consists of 17 specially trained RNs and 2 licensed Social Workers. Together they partner with primary care doctors, geriatricians, and pharmacists to ensure their patients get the most complete information and access to services available to them. The partnership with the pharmacy in particular is key to a smooth transition to a higher quality of care. The team is available on-call and by appointment. Every CCC-followed patient receives at least one outreach call within 24 hours of discharge, which is crucial to effective patient support. Linda Smith, RN, MSN, MSHA, Senior Delivery System Leader, Nursing & Quality, explains that the CCC takes the best assessment and teaching skills that RNs have and focuses them on the patients who need them the most.
Data shows a positive impact:
For SNF transitions alone, results from 100 patients showed that 2.4% of CCC-followed patients were hospitalized vs. 14% of the usual-care patients. In looking at trips to the ED, 7% of CCC-followed patients made a trip, compared to 16% of usual-care patients. There were no SNF readmits over a 60-day period among the CCC-followed patients, while 13% of usual-care patients became readmitted during that time. This translates into significant cost savings of CCC-followed patient care, which is further enhanced by a $188,883 overall cost avoidance for patients followed by a CCC provider within 60 days of their initial SNF discharge.
Patient Care Quality benefits:
Member response is phenomenal. They appreciate that the outreach and assistance is coming at a time when they are completely overwhelmed. Jeryl McGaw, MS, RN, ND, Regional Program Manager Chronic Care Coordination, says "You are going from a situation where everything is being done to you and for you to one where you constantly have to make sure you are getting these things accomplished for yourself. Our members tell us they could not have gotten on with their life without the assistance of their CC Coordinator." The quality of service and support that CCCs provide is so high that that it touches their patients deeply. For example, parents of a pediatric patient sent a Mothers' Day card to their coordinator, saying that they considered them to be a part of their family.
The Vohs award recognizes and honors projects that advance quality of care, showcase innovative techniques and knowledge that can be transferred throughout the Program, and underscore the value of multidisciplinary team work. Colorado 's Chronic Care Coordination program embodies this criteria. Although this is one of the few nursing-related programs to be honored with such an award, the CCC program exemplifies the level of commitment that nurses have for the care of their patients. Care of the body, caring for life.
Links to:
- Nursing Pathways CO
- Vohs Award page (on Dept. of Care & Svc Quality site)
