Patients with Chronic Diseases Benefit from Support Targeted to the Level of Care They Need

Patients who have chronic diseases or who are at risk of developing one require different levels of support and care. Kaiser Permanente’s Northern California region developed a strategy to improve the care and outcomes for these patients by dividing their care into three well-defined levels of specialty care. Kaiser Permanente’s Colorado region later adopted the strategy to include a telephonic cardiac medication management service.

Excerpt from Commonwealth Fund case study:

Kaiser Permanente: Bridging the Quality Divide with Integrated Practice, Group Accountability, and Health Information Technology

“The Northern California region uses a population and patient-panel management strategy to improve care and outcomes for patients who have–or who are at risk for developing–chronic diseases. This approach is built on the philosophy that a strong primary care system offers the most efficient way to interact with most patients most of the time, while recognizing that some patients need additional support and specialty care to achieve the best possible outcomes. Patients are stratified into three levels of care:

  1. Primary care with self-care support for the 65 percent to 80 percent of patients whose conditions are generally responsive to lifestyle changes and medications.
  2. Assistive care management to address adherence problems, complex medication regimens, and comorbidities for the 20 percent to 30 percent of patients whose diseases are not under control through care at level one.
  3. Intensive case management and specialty care for the 1 percent to 5 percent of patients with advanced disease and complex comorbidities or frailty.

Level one emphasizes a proactive team approach that conserves physician time for face-to-face encounters by enhancing the contributions of ancillary staff (medical assistants and also nurses and pharmacists in some locations) to conducting outreach to patients between visits. . .

At level two, care managers (specially trained nurses, clinical social workers, or pharmacists) support the primary care team to help patients gain control of a chronic condition. . . .

An example of intensive case management (level three) is a cardiac rehabilitation program called Multifit for patients with advanced heart disease, such as those recovering from a heart attack or heart surgery. Nurse case managers provide telephonic education and support for up to six months to help patients make lifestyle changes and reduce their risk of future cardiac events. Aided by the EHR and a patient registry, the Colorado region enhanced the program by adding a telephonic cardiac medication management service provided by clinical pharmacy specialists, with ongoing follow-up until patients achieve treatment goals and can be transferred to primary care for maintenance. Results for patients participating in the Colorado program included the following:

  • Cholesterol screening increased from 55 percent to 97 percent of patients, while cholesterol control has almost tripled from 26 percent to 73 percent of patients. The Colorado plan ranked first among health plans nationally in 2007 on a measure of cholesterol screening for patients with cardiovascular conditions.
  • Relative risk of death declined by 89 percent among those enrolled in the program within 90 days of a cardiac event, and by 76 percent for those with any contact with the program. An estimated 260 major cardiac events and 135 deaths have been avoided per year because of these improvements.”

Keywords: assistive care management, care coordination, care teams, chronic care, chronic disease management, communication, specialty care, case management, electronic medical record, evidence-based medicine, health information technology, Kaiser Permanente, kp healthconnect, clinical collaboration, integrated care, Northern California, patient support, population health, preventive care, treatment, value


Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317

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