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Community Care Coordination Service (CCCS)

jessievenegas Jessie Venegas — 10/01/2009

This program focuses on complex medical/chronic disease populations. It was created as part of a two-year funding program by the Sunshine Network of the Veterans Health Administration (VHA) to test disease management principles, the care coordinator role, and the effective use of technology to maintain veterans in their homes. Seven hundred and ninety-one veterans were recruited in this five- project program and enrolled in the Community Care Coordination Service (CCCS). The program was conceptualized around and designed by network field staff as an "aging in place" model. The purpose behind the integration of the care coordinator role with technology was to improve health status, increase program efficiency, and decrease resource utilization. Evaluation of the program showed a 40% reduction in emergency room visits, 63% reduction in hospital admissions, 60% reduction in hospital bed days of care, 64% reduction in VHA nursing home admissions, and 88% reduction in nursing home bed days of care. All Performance Improvement outcomes reached or exceeded the targeted goals, and a functional assessment revealed five significant improvements out of 10 domains of the SF 36V.


Goals Prevention:
Promotes adecuate understanding levels on the community about the importance of prevention , Focuses on social inequalities
Goals Detection:
Promotes early intervention through primary health care measures , Provides registries and patients contact systems , Shows new evidence on the importance of early detection, including guidelines of effective practices
Goals Treatment:
Develop basic elements for an integrated health system , Provides support health policies to facilitate the planning and integration at locally and regionally , Strengthens cooperative local groups to provide integral services , Ensures the best quality of health services , Promotes the appropriate use of medicines , It facilitates the management by processes , Emphasizes the care of pluri-pathological and fragile patients , Promotes electronic health information systems to improve the quality of care
Goals self-management:
Refocuses the health system to support self-management , Promotes patient involvement in planning services , Improving support services with an emphasis on peer support, the disabled and carers , Allows home care , Allows remote support to patients and their carers from health professionals







Practices Map



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