Chronic Care Management

What is it?

Nurses, acting as case managers, reach out to patients to support the frail and chronically ill's transition out of the hospital to help maintain good health and assist in the coordination of their healthcare experience.

Why is it important and what are the benefits to the patient?

Research has indicated that about half U.S. patients with asthma, congestive heart failure, depression, or diabetes receive appropriate treatment for those conditions. The goal of the care management programs at the John Muir Physician Network is to improve the coordination of care for our patients with chronic health conditions, preventing hospital admissions, emergency room visits, and improving quality of life.

Care Transitions Interventions (CTI)

What is it?

The goal of the Care Transitions Intervention program is to improve the continuity of care for older adults with chronic conditions across different health care settings. Following hospital discharge, older adults often require care from different medical practitioners in many different settings. This program is designed to ensure that each transition between settings goes smoothly, and supports the patient's personal goals.

Why is it important and what are the benefits to the patients?

The focus of the program is to empower patients to understand their conditions and successfully manage their health care needs. The purpose of the program is to improve care by improving communication. Ensuring the proper information is shared between the healthcare settings, older patients, those with ongoing medical problems, and the caregivers during care transitions, such as discharge from the hospital to home.

Care Management System

What is it?

Case management is a collaborative process of assessment, planning, facilitation and advocacy for our patients, with the objective of providing quality outcomes over the entire course of treatment for the individual patient. This includes coordination of all care for the duration of the patient's condition (both inpatient and outpatient), often for the rest of his life. The John Muir Physician Network has implemented a software tool that helps case managers be more efficient in helping multiple patients in the coordination of their care.

Why is it important and what are the benefits to the patient?

This technology application will allow case managers to aide more patients by providing education, coordination of needed health care services, navigating through the often complex health care system, and empowering patients to understand and successfully manage their conditions.