Chronic Care Coordination aims to reduce acute care utilization among patients transitioning between settings of care and patients with multiple chronic conditions. Specifically, the model’s primary goals are to streamline patient transitions across settings of care and to reduce inpatient hospitalizations, lengths of stay and emergency department visits.
In 1998, KP CO started the Chronic Care Coordination program to target patients with chronic conditions, but over the years the program's focus became diffuse and lacked clear outcome metrics. So in 2003, KP Colorado began a redesign of the program with the establishment of an advisory committee comprised of clinical care coordinators, nurses, research staff, physician consultation, and the coordinator of hospital services. The committee conducted an evidence-based review of the literature and redesigned the Chronic Care Coordination program based on their review.
Moving forward, CCC is looking to partner with other management programs (i.e. diabetes, heart failure, geriatric care coordination).