Through mostly phone-based interactions, nurses help complex patients and patients transitioning between care settings understand their care plans and instructions and access the clinical services they need.

Chronic Care Coordination targets patients who have been or are likely to be heavy users of expensive inpatient care.  Specifically, the program focuses on patients with at least one of the following characteristics:

• Four or more chronic illnesses
• Recent hospitalization
• High utilization of the emergency department
• Recently discharged from a skilled nursing facility

The CCC program has only 3 exclusionary criteria:  pregnancy, chemical dependency, and untreated psychosis.

The average age of patients treated by Chronic Care Coordination is 62.

Kaiser Permanente Colorado Region is a not-for-profit integrated health care system with a health plan and physician group.  In Colorado, KP contracts with hospitals.  In the Denver metropolitan region, KP has over 450,000 members.

The model is intended for the outpatient setting, with a focus on transitions from acute care and long-term care settings.