Transforming Chronic Care Partnerships

Transforming Chronic Care Partnerships

The John Muir Physician Network’s Transforming Chronic Care (TCC) Programs are comprised of three programs to address the fragmentation of the health system by improving the coordination of care for low-income and Contra Costa Health Plan patients through telephonic support and site visits.

  • Care Transitions Interventions is a program that supports the patient in the phase of care from the end of hospitalization until they are stable at home, by utilizing nurses and to reconcile medications help the patient produce a personal health record, and coach the patients about their condition. Patients are evaluated at the end of four weeks and assessed for continuing case management needs.
  • Tel-Assurance is a program that helps monitor the status of patients with CHF and COPD between visits. Patients call in daily to an automated service and answer approximately six short questions. Nurses monitor the responses and follow-up with patients who signal a significant change in condition to determine the appropriate course of action.
  • The more severely ill patients are referred to the Complex Case Management program and receive monthly or weekly phone calls from a case manager who provides education, support and coordination of care.

Partners

  • Contra Costa Health Plan