Post-Discharge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs

Post-Discharge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs

Snapshot
Summary
Kaiser Permanente Colorado Region’s chronic care coordination program employs coordinators to provide telephone-based support to patients recently discharged from the hospital or a skilled nursing facility and to other high-risk enrollees. Coordinators identify care needs, help individuals develop self-management skills, and ensure access to needed clinical and social services. The program has led to significant reductions in hospitalizations and emergency department visits, resulting in an estimated $4 million in savings to Kaiser Colorado. The program has also encouraged more patients to complete their followup care, improved medication compliance, and yielded high levels of provider and patient/family satisfaction.

See the Description section for new information about program eligibility and assessment and the Results section for updated information on inpatient re-admissions and medication compliance (updated November 2009).

Evidence Rating
Moderate: The evidence consists of comparisons of key metrics (readmission rates and ED visits) between enrollees receiving program services and similar enrollees receiving usual care, physician and patient survey data, and cost savings.

Developing Organizations
Kaiser Permanente Colorado

Date First Implemented
2003

Patient Population
Geographic Location > State; Vulnerable Populations > Frail elderly; Medically or socially complex




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AHRQ Innovations Exchange | Post-Discharge Telephone Followup With Chronic Disease Patients Reduces Hospitalizations, Emergency Department Visits, and Costs