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.