Sutter Care Coordination Program

Descripción de la práctica:
The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions. The program reduced patient visits to specialists by 12.7 percent, emergency department (ED) visits by 25.9 percent, and hospitalizations by 18.3 percent. Because the program’s sponsor, Sutter Health Sacramento-Sierra, serves many patients on a capitation basis, much of the savings achieved through avoided medical costs are shared by its physician organizations and hospitals. The program was the first of its kind to receive Disease-Specific Certification from The Joint Commission. The Sutter Care Coordination program consists of two main elements. The primary element is a team of registered nurses (RNs), medical social workers (MSWs), and general health care coordinators (HCCs) that works with patients and their families/caregivers to keep those with multiple chronic conditions as healthy as possible through coordination of care; patient education; referral to appropriate medical, psychosocial, and community services; and ongoing monitoring and troubleshooting as needed. The team is supplemented, when appropriate, by specific disease management programs for those patients with heart disease, diabetes, and/or asthma, as well as those in need of anticoagulation management. Key elements of the program are described below: • Patient Referral to Care Coordination Program • Care Coordination Team and Primary Care Coordinator • Initial Interview/Home Visit and Ongoing Monitoring • Disease Management Programs for Select Patients

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