Transforming Chronic Care Seniors Program

Transforming Chronic Care Seniors Program

Transforming Chronic Care improves the coordination of care for low-income, frail, elderly patients through phone support and site visits. Transforming Chronic Care has four component programs:

  • Care Transitions Intervention supports patients from the end of hospitalization until they are stable at home. Nurses and nursing students reconcile medications, help the patient produce a personal health record, and coach the patients about their condition.
  • Tel-Assurance helps monitor the status of patients with congestive heart failure or chronic obstructive pulmonary disease between physician office visits.
  • Disease Management provides ongoing education and coaching for patients with chronic conditions. Patients receive phone calls from a case management nurse as needed to assess self-management skills.
  • Complex Case Management is provided to severely ill patients. Participants receive regular phone calls from a case management nurse who provides education, support, and coordination of care.

John Muir Health's medical center, clinics, and staff basically saved my life – I don't know what I would have done without them.

Participant Story

Emma, 79 years old, lives alone in an apartment with a restricted income and limited social contact.  She has chronic obstructive pulmonary disease (COPD) and is on constant oxygen.  Emma's condition has resulted in frequent hospital admissions and she "basically doesn't have good days anymore."  With the support of case management and Tel-Assurance services, Emma's living situation has been transformed to a comfortable environment where she receives care in the least restrictive setting. Every morning, she calls a toll-free number to answer a two minute survey about how she is feeling.  Her answers are compared to the previous days to monitor her health status.  When she reports respiratory symptoms her medication dosage is adjusted and a trend report of her variances is sent to her primary care physician.  She also receives regular telephone support from a case management nurse who empowers Emma to manage her health.  The constant monitoring has allowed her to avoid readmissions for COPD.   Emma told her case manager that "John Muir Health's medical center, clinics, and staff basically saved my life – I don't know what I would have done without them." Unfortunately, even good stories have sad endings.  Recently Emma died, but she was able to do so peacefully at home in her favorite chair.

Highlights

  • In 2011, 556 low income seniors with Congestive Heart Failure (CHF) and/or Chronic Obstructive Pulmonary Disease (COPD) were referred to the program.
  • 536 low income patients were engaged in one of the four programs.
  • In 2011, the programs were able to demonstrate that they reduced inpatient readmissions from 7.7 percent to 6.7 percent for participating patients.
  • The 2011 readmission rate for CHF patients in Tel-Assurance decreased from 2010 (12.2 percent to 11.1 percent) and was less than control group rate of 19.2 percent.

Partners

Contra Costa Health Plan