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Postdischarge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs

jessievenegas Jessie Venegas — 11/01/2009

Kaiser Permanente

Kaiser Permanente Colorado Region’s (KPCO) chronic care coordination program employs coordinators to provide telephone-based support to patients recently discharged from the hospital or a skilled nursing facility (SNF) and to other high-risk enrollees. Coordinators identify care needs, help individuals develop self-management skills, and ensure access to needed clinical and social services. The program has led to significant reductions in hospitalizations and emergency department (ED) visits, resulting in an estimated $4 million in savings to KPCO. The program has also encouraged more patients to complete their follow up care, improved medication compliance, and yielded high levels of provider and patient/family satisfaction.


All

Goals Prevention:
Promotes adecuate understanding levels on the community about the importance of prevention
Goals Detection:
Provides registries and patients contact systems
Goals Treatment:
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

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1/01/2007

Progress

UNITED STATES OF AMERICA

Colorado

Colorado

Denver

Denver
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