Login  | Join


jessievenegas Jessie Venegas — 12/01/2009

Sutter Care Coordination Program

This program offers an integrated delivery system comprised of 10 not-for-profit hospitals and 900 community-based physicians. Its care managers are coordinated with the help of a user-friendly software platform that helps them identify potential problems and direct patients to appropriate healthcare providers, while providing evidence-based national treatment guidelines, medical information and other resources, making patients less likely to end up in the emergency room or be hospitalized, thus avoiding costly health complications in the future. CenVaNet has seven care managers (registered nurses and social workers), each treating between 50 and 70 patients, who provide in-home, telephonic and online care management focusing on four chronic diseases common in the Medicare population: congestive heart failure, chronic obstructive pulmonary disease, diabetes and asthma. To supplement care managers’ patient education efforts, the program offers other resources for patients to learn about their health, such as printed and electronic materials.

Fragility, pluripathology/polipathology and/or complex chronic diseases

Goals Prevention:
Funding for detection programs , Creates healthy environments , 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 , Advances public education on the importance of early detection
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 , Improving access to health services across the entire spectrum, from prevention to treatment , Ensures the best quality of health services , Promotes the appropriate use of medicines , Promotes the training of health professionals , 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

Through the care management software technology, patients can take advantage of a vast library of reliable health information and access patient tools designed to improve their care and increase their knowledge of their chronic conditions. This technology also addresses the problem of fragmentation of information. Care managers, physicians and patients are linked together by using the same software, increasing communication and improving the quality of care. This is further strengthened by automated interfaces that allow hospital labs, home care companies and others involved in a patient’s care to download information directly into our software platform. This eliminates the need for patients to recall which diagnostic tests they had performed and why. All of these capabilities are important steps in improving the care Medicare patients receive, and particularly benefit patients with multiple chronic conditions.






2201 West Broad Street, Suite 202

VA 23220-2
Practices Map



Please log in to post your comment
Francisco Martos Pérez
28/11/2011 22:50

A very comprehensive approach to chronic patients care, emphasizing the role of registered nurse and the use of electronical medial records.