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Service Delivery Innovation Profile

Chronic Care and Disease Management Improves Health, Reduces Costs for Patients With Multiple Chronic Conditions in an Integrated Health System

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The Sutter Care Coordination Program combines chronic care and disease management to address the medical and psychosocial needs of individuals with multiple chronic conditions. The program reduced patient visits to specialists by 24 percent, emergency department visits by 13 percent, and hospitalizations by 39 percent. Because the program's sponsor, Sutter Health Sacramento-Sierra, serves many patients on a capitation basis, much of the savings achieved through avoided medical costs are shared by its physician organizations and hospitals. The program was the first of its kind to receive Disease-Specific Certification from The Joint Commission.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of utilization rates between program participants and a nonrandomized control group of patients not participating in the program, along with pre- and post-implementation comparisons of hospital admissions, physician visits, ED visits, and patient and caregiver understanding.
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Developing Organizations

Sutter Health Sacramento-Sierra Region
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Use By Other Organizations

  • To date, this model has not spread to many other health care delivery systems because of the unique nature of the reimbursement system in the geographical area in which Sutter Health Sacramento-Sierra operates. Even in other parts of the Sutter health care system, this model has limited applicability because those systems lack the clinical integration and widespread capitation that exist in Sutter's Sacramento-Sierra region.
The care coordination program was implemented in 1994. The disease management components were added between 2001 and 2005.begin pp

Patient Population

Vulnerable Populations > Medically or socially complexend pp

Problem Addressed

The population of individuals with one or more chronic illnesses is large and growing rapidly, and the ability of the fragmented, fee-for-service health care system to meet the complex needs of these patients is limited.
  • A large population: Forty-two percent of the American population—125 million people—live with a chronic medical condition. In California, 14 million adults (38 percent) live with at least one chronic condition, and more than one-half have multiple chronic conditions. Of the 38 percent of all Californians living with one or more chronic medical conditions, nearly one-half have hypertension, asthma, heart disease, or diabetes.1
  • A growing population: Between 1990 and 2030, the number of older people is projected to rise from 31.6 million to more than 65 million, resulting in a dramatic growth in the number of persons with one or more chronic illnesses.2
  • A costly population: Individuals with chronic illness already account for more than 80 percent of all health care spending, and spending on these individuals is expected to increase substantially over the next 2 decades.1
  • A population that the current health care system is ill-equipped to serve: Existing clinical research, practice guidelines, and physician education rarely consider the complex clinical, social, and financial needs of patients with multiple chronic health issues. In addition, the culture, structure, and financial incentives of hospitals and medical practices often limit health care givers' ability to meet the complex needs of chronically ill patients. Under fee-for-service reimbursement programs, such as Medicare, hospitals and medical groups benefit financially from repeated visits to the physician or hospital, and they are often not reimbursed for investing in programs, such as case management and disease management, that might improve outcomes and reduce costs for those with multiple chronic conditions. Because it was an integrated system that was paid primarily on a per capita basis, Sutter had an incentive to address these problems and started to do so in the mid-1990s, earlier than most organizations.

What They Did

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Description of the Innovative Activity

After testing several models of chronic disease management and care coordination, Sutter arrived at the following approach. The Sutter Care Coordination Program consists of two main elements. The primary element is a team of registered nurses, medical social workers, and general health care coordinators who work with patients and their families/caregivers to keep those with multiple chronic conditions as healthy as possible through coordination of care; patient education; referral to appropriate medical, psychosocial, and community services; and ongoing monitoring and troubleshooting as needed. The team is supplemented, when appropriate, by specific disease management programs for those patients with heart disease, diabetes, or asthma, as well as for those in need of anticoagulation management. Beginning in January 2009, Sutter also began integrating a transitions of care process, based on the model developed by the University of Colorado in 2002, into its Care Coordination Program to ensure that transitions between providers and health care settings are respectful, coordinated, and efficient.3 Key elements of the program are described below:

Patient Referral to Care Coordination Program

Both elderly and nonelderly patients are eligible for the program. Patients are referred to the program, not because they have a specific chronic disease, but rather because they are struggling with chronic care management and coordination needs. Criteria for referral to the program include:
  • Multiple hospital admissions
  • More than two emergency department (ED) visits within 6 months
  • Discharge from an acute or skilled nursing setting
  • Poor nutritional status
  • Medication noncompliance or other related issues
  • Lack of community and social support needed to maintain wellness
  • Request from caregivers
  • Anticipated high utilization of medical services after discharge from the hospital
  • Severe, chronic asthma in children

Care Coordination Team and Primary Care Coordinator

The care coordination team consists of registered nurses, medical social workers, and health care coordinators who work out of physician offices. For each patient, one team member serves as the primary care coordinator, with registered nurses taking complex patients in whom medical issues dominate and medical social workers taking complex patients who have psychosocial issues. The primary care physician (PCP) is not a formal part of the team. Instead, the care coordination team serves as an intermediary between the patient and the physician to address any issues that arise. The PCP does help develop the care plan and is in frequent contact with the team. The team structure helps streamline communication, so the physician or specialist hears about a patient from one individual. To facilitate communication, registered nurses and medical social workers work in physician offices to support patients and be part of the single point of contact, and coordinators work in a regional office to provide ongoing monitoring and support, as well as to assist the case managers with referrals to a wide variety of resources. Registered nurses and medical social workers each handle between 60 and 80 patients. As complex patients are stabilized, their ongoing monitoring is transferred to a coordinator, and new patients are added to the registered nurse or medical social worker caseload. Health care coordinators handle between 250 and 300 patients and can refer cases to a registered nurse or medical social worker, if necessary, because of changes in the patient's condition.

Initial Interview/Home Visit and Ongoing Monitoring

After referral, the primary care coordinator contacts the patient to provide information about the Sutter Care Coordination Program and schedule an initial interview, which may take place in the home, office, or by telephone. The key goal for this initial assessment phase is to work with the patient and/or caregiver to identify pertinent issues and problems that need to be addressed and then to develop a care plan that deals with those issues and problems. The coordinator teaches patients about their chronic condition(s) and helps match them to needed Sutter and community services, including resources for meals, personal care, and other assistance. The coordinator also routinely monitors patients, typically through periodic telephone calls, to detect any potential exacerbation of a chronic illness as early as possible—before the need for an acute intervention arises.
  • Patients with complex medical issues: A registered nurse case manager performs an assessment for patients whose medical needs are dominant and include complex and ongoing medical conditions, end-of-life issues, or management of acute episodes. During the initial contact, the nurse performs the medical assessment, identifies goals and priorities, provides individualized education and instruction, reviews medications, and performs mental health status and depression screens. The nurse will make appropriate referrals to community resources (e.g., financial support, senior care) and communicate the key points from the initial assessment to the physician. The registered nurse continues to monitor the patient by telephone as appropriate and to work with the physician in coordinating care. Often, the registered nurse case manager works with frail elderly patients who require the following kinds of support:
    • Assistance with end-of-life issues and advance directives, including identification of patients who might benefit from hospice care and discussion of these potential benefits with the patient, family, and provider.
    • Identification and referral of appropriate patients to needed services both inside and outside of the Sutter system, such as a diabetes clinic or support services for patients with Alzheimer's or dementia.
    • Identification and arrangement of services for patients with nutrition issues, including education and referrals to community-based services, such as Meals on Wheels. Malnutrition has been shown to increase the risk of institutionalization, length of stay, and the time it takes injuries to heal.
  • Patients with complex psychosocial conditions: A medical social worker makes the first visit if the patient is unstable and has complex psychosocial conditions or requires a home assessment, psychosocial evaluation, or crisis intervention. The social worker performs the home assessment and daily living and depression screens, reviews medications, and helps patients and families get needed support. The social worker provides ongoing telephone monitoring for families in crisis, makes referrals to appropriate government and community programs, and communicates with the physician.
    • Stable patients: A coordinator makes the initial contact if the patient is relatively stable. The coordinator monitors established patients with heart failure and other chronic illnesses and educates the patient about goals, prevention, and utilization of community resources to manage their diseases. The coordinator also performs ongoing telephone monitoring of patients and refers patients to the registered nurse or social worker when changes require additional assessment and intervention. The coordinator also communicates with the physician.
    • Transfers between care coordinators: Cases are transferred between team members as needed, with special emphasis placed on identifying and providing education and monitoring related to chronic conditions. Incidents such as falls, low body mass index, frequent hospital or ED visits, medication problems, and loss of daily living activity capacity can trigger transfers between team members. Relatively straightforward, nonclinical issues, such as an issue related to transportation, may be forwarded to a coordinator who has expertise in identifying resources in the community. A complex clinical issue, such as a medication noncompliance issue or a newly developed need for a medical assessment, would be directed to the registered nurse.

Inhospital Monitoring

When a patient who is enrolled in the program is hospitalized, the care coordination team works to reduce length of stay, promote timely discharge, and decrease the risk of readmission through the following activities:
  • Communicating premorbid functional status and prior history of hospital-related complications to hospital case managers
  • Arranging for discharge support before scheduled admissions
  • Communicating discharge needs to hospital case managers
  • Assessing the adequacy of the discharge plan in meeting the patient's needs
  • Providing ongoing monitoring of discharge plans after hospitalization

Transitions of Care Process

The transitions of care process is a patient-centered approach to ensuring that transitions between providers and health care settings are respectful, coordinated, and efficient. The process supports patient safety whenever a patient transitions to a different care setting and focuses on medication self-management and reconciliation, primary care and specialist followup, patient knowledge about important clinical indicators about his or her condition, and the provision of adequate services and support systems. All new as well as existing Care Coordination Program patients began undergoing this process in January 2009. Medicare and Medicare Advantage patients going home without home health aid and meeting any one of three criteria (i.e., greater than three admissions per year; greater than three chronic conditions, such as dementia, heart failure, chronic obstructive pulmonary disease, diabetes, and cancer; and polypharmacy of greater than seven medications) are followed through this process. Transitions of care visits are initiated by health care coordinators making the initial contact postdischarge for new patients to discuss medical care followup, discuss social support and equipment, and arrange for the next call with a registered nurse or medical social worker with appropriate handoff. The case manager (registered nurse or medical social worker) focuses on medication management and other red flag issues. Future calls are made by either the health care coordinator or case manager based on the case manager's initial assessment. The care transitions model is followed for documentation and followup. Followup is conducted at designated times. Normal followup occurs 2 days after discharge, 7 days later, another 7 days later, 14 days later, and again 14 days later. If, after the second 7-day later call, case managers determine that the patient is stable, subsequent followup visits are not necessary until 30 days postdischarge.

Advanced Illness Management (AIM)

AIM is a program under the auspices of Sutter Care at Home. The program staff identifies appropriate patients for the program and facilitates referrals. In addition, the staff provides ongoing telemonitoring, care coordination, and linkages to the patients' physicians for patients in the AIM program. The clinicians receive special training in advanced care planning and symptom management for patients with advanced or end-stage chronic illness who desire to continue disease-modifying therapy and could benefit from a palliative care approach.

AIM provides care management to patients with end-stage illnesses who are not yet ready for hospice. Patients receive high-touch care management intervention with a focus on advanced care planning, symptom management, and care coordination. Patients who are eligible patients include those with advanced or end-stage chronic illnesses whose life expectancy is 12 months or less (metastatic/recurrent cancer, cardiac disease or congestive heart failure, chronic obstructive pulmonary disease/chronic lung disease, end-stage renal disease with comorbidity, liver disease, and neurological disease).

Disease Management Programs for Select Patients

Disease management activities are part of Sutter's regional Care Coordination Program. The various disease management programs focus on a few specific medical issues, including congestive heart failure, asthma, ongoing oral anticoagulant treatment, and diabetes. These programs have teams of nurses and support staff who focus on the specific disease. When a psychosocial issue is identified, the care coordination team becomes involved to provide support. Although this approach includes traditional disease management model methods, including regular telephone calls to patients for consultation, support, and education as well as medication adjustments, in the Sutter program it is not a distant, third-party nurse who is making the call. Instead, it is a team of experts that specializes in the disease and works closely with the patient's PCP as part of the patient's coordinated care. Sutter found it more cost-effective to train support staff to be a disease management specialist and handle patient education and monitoring issues, instead of a registered nurse. Issues are escalated to the nurse based on best practice guidelines.

Context of the Innovation

Sutter Health Sacramento-Sierra Region is a not-for-profit integrated health care delivery system, with four hospitals on five campuses, two aligned medical groups, and one independent physicians' association. The system serves three counties and also owns nursing facilities and home health care and hospice organizations.

Sutter's decision to develop the Care Coordination Program was driven by the chronic nature of many patients' needs combined with the financial incentives embedded in this highly integrated health care system. A substantial portion of Sutter's business is provided on a capitated basis. Under capitation, payers pay Sutter a fixed amount of money per month to care for an individual patient or "enrollee," regardless of the amount of services provided during the month. As a result, it benefits Sutter's hospitals and physician organizations financially to prevent unnecessary hospitalizations, ED visits, and physician visits for these patients, as the system reduces costs without negatively affecting revenue streams. This financing model helped to forge a financial partnership between the hospitals and physician groups, along with a strong commitment by both parties to invest in preventive care and care management practices designed to keep clients healthy, reduce disability, and optimize functional status and well-being. After trying a variety of models, Sutter settled on the current approach in early 2001.

Did It Work?

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The Care Coordination Program has decreased inappropriate use of health care resources, reduced costs, and improved patient and caregiver understanding of disease process and symptom management.
  • Reduced utilization: The following health care utilization rates for 2011 compared the experience of Sutter patients who received care coordination services against Sutter patients who also had multiple chronic conditions but did not receive coordinated care services. Patients receiving care coordination had:
    • 24 percent fewer visits to specialists
    • 13 percent fewer ED visits
    • 39 percent fewer hospitalizations for acute care
    • 33 percent fewer outpatient visits at hospitals
    • 38 percent fewer home health care visits
    • 15 percent fewer PCP visits
  • Cost savings: An evaluation of Sutter's Care Coordination Program by The California HealthCare Foundation found that the program saved money by reducing inpatient admissions, including intensive care unit stays and "observation" stays, for Medicare fee-for-service patients (Sutter loses money on many of these Medicare fee-for-service admissions).3 Sutter's internal studies have also shown meaningful cost savings and return on investment from the heart failure and anticoagulation disease management programs due to reductions in physician visits, ED visits, and hospital admissions, which more than offset the increased home health care and skilled nursing facility costs. Because 42 percent of the patients enrolled in the care coordination program have traditional fee-for-service insurance, reductions in unnecessary services for these patients can have a negative impact on Sutter's revenue stream.
  • Increased patient and caregiver understanding of disease processes and symptom management: Many of the benefits achieved are due to the program's ability to better prepare the patient or caregiver to manage ongoing chronic conditions, which keeps the patient healthy and therefore avoids the need for acute interventions. For example, the program has led to decreased caregiver anxiety and lower rates of patient injury (e.g., due to home safety evaluations and modifications).
  • Readmission rate: The 30-day readmission rate for patients who were followed using the transitions of care protocols was 5.27 percent during the first half of 2009. In comparison, from 2003 to 2004, nearly one in five patients (19.6 percent) were readmitted within 30 days of discharge among all Medicare fee-for-service patients.4

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of utilization rates between program participants and a nonrandomized control group of patients not participating in the program, along with pre- and post-implementation comparisons of hospital admissions, physician visits, ED visits, and patient and caregiver understanding.

How They Did It

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Planning and Development Process

Key steps in the planning and development process are described below:
  • Finding the right structure and model: Sutter went through a variety of iterations before settling on the current care coordination/disease management model.
    • Initial approach: The roots of the current Sutter program began in the 1990s with the development of a hospital-wide Continuum Case Management Department that replaced the separate case management departments that existed within each clinical department.
    • Development of current approach: Beginning in late 1999 and continuing into 2000, quality, case management, and nursing leadership from the hospitals came together and decided to integrate these services into a continuum of care management services that included medical and psychosocial services, patient education designed to empower patients and family members to be advocates for their care, and links to health care and other services in the community.
  • Extending the model outside the hospital: Care management improvements made in the hospital arena were migrated to Sutter's outpatient care clinics and physician organizations. Sutter defined the role of primary care in its care coordination model by establishing guidelines on when patients should see specialists, including what should be done before the referral and when the patient should be referred. One key aspect of the program was providing registered nurses and medical social workers to support physician groups, which helped to reduce physician objections to this kind of initiative.
  • Integrating disease management: Over time, pieces of the disease management model were folded into the Care Coordination Program to prevent the disconnect and poor communication that had resulted from the outsourced disease management programs.
  • Continually refining the model: The leaders of the program meet periodically to discuss how it might be improved and expanded, including the disease management component. The team continually refines nursing assessment and management roles, and realigns staff roles as needed. However, the specific disease dictates what expertise is needed and how responsibilities are divided. The program for patients on oral anticoagulants, for example, relies more heavily on registered nurses than coordinators because of the need to focus on medications.

Resources Used and Skills Needed

  • Staffing: One registered nurse serves approximately 18 physicians, and 1 medical social worker serves 18 physicians. One coordinator can work with a team of two registered nurses and one social worker. Coordinators may have a degree in social work, gerontology, or a health-related field; be a licensed visiting nurse; or have a bachelor's degree with previous experience in care coordination or the geriatric population. The Sutter program, which includes multiple hospitals and physician practices, also has a clinical pharmacist who is available to provide advice to the staff and meet with individual patients and a Medicare director who provides guidance to team members on complex clinical matters and communicates with the patient's PCP or specialists.
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Funding Sources

Sutter Health Sacramento-Sierra Region
The original case coordination initiative was funded by a grant from three health maintenance organizations. Since the grant funding ended, the program has been supported internally, with the costs integrated into Sutter's regional case management budget. At present, Sutter's hospitals fund 60 percent of the program, with physician organizations covering 40 percent of the costs. As noted, the program more than pays for itself by generating cost savings through reduced specialist and ED visits and hospitalizations, and enhanced efficiencies in the physician practice.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Conduct an analysis of the current infrastructure for chronic care management within the health care system, and discuss and define how a care manager could help to improve the coordination and ongoing management of care for patients with one or more chronic conditions.
  • Determine staffing needs by evaluating the size and nature of the population that needs to be served, using the expected caseloads for a registered nurse, medical social worker, and health care coordinator.
  • Place care managers in physician offices to gain their buy-in and enhance the effectiveness of the program.
  • Seek external funding from private and government organizations, such as insurers, that stand to benefit from the program. Over time, the funding needs for heavily capitated organizations may diminish as cost savings accrue from the program.

Sustaining This Innovation

  • Identify physician champions to advocate for expansion: Having care coordination staff and disease management programs in doctors' offices has improved communication with PCPs, who now have become strong political supporters of the program, agreeing to fund 40 percent of its costs and advocating for its expansion to traditional Medicare fee-for-service patients.
  • Use health care coordinators and medical social workers to take on routine nursing tasks: Like many organizations, Sutter faces a nursing shortage and has a limited budget for nursing. Coordinators can help reduce the impact of the shortage by effectively performing disease management and patient monitoring tasks at a reduced cost. Social workers can also perform many traditional nursing tasks, except for clinical oversight/assessment and medication reconciliation.
  • Work with health care plans and vendors to avoid care management overlap: Sutter's internal chronic care management programs sometimes duplicate attempts by health care plans and their disease management vendors to intervene with the same patient. This duplication can prove frustrating to patients and physicians, who prefer not to respond to multiple personnel.
  • Develop financial partnerships with physicians: The success of the program at Sutter is due in part to the tight economic linkages between hospitals and physicians within the organization, where both parties share capitated risk.

Use By Other Organizations

  • To date, this model has not spread to many other health care delivery systems because of the unique nature of the reimbursement system in the geographical area in which Sutter Health Sacramento-Sierra operates. Even in other parts of the Sutter health care system, this model has limited applicability because those systems lack the clinical integration and widespread capitation that exist in Sutter's Sacramento-Sierra region.

Additional Considerations

  • Best results in heavily capitated systems: The program depends on capitation to ensure that any financial benefits actually accrue to the innovating organization. Otherwise, under the fee-for-service model, the innovator may lose revenues as resource utilization declines, while simultaneously bearing incremental investment costs for care management services (e.g., staffing) that are often not reimbursed by payers. For example, Medicare does not provide funding for the case management services, even though many Medicare recipients benefit from the program.
  • External recognition: In 2004, The Joint Commission on Accreditation of Healthcare Organizations awarded four of Sutter Health Sacramento-Sierra's care management programs the Gold Seal of Approval for achieving Disease-Specific Care Certification, including the Care Coordination Program. The Joint Commission's Disease-Specific Care Certification is awarded to hospitals and health care systems that demonstrate compliance with consensus-based national standards, effective use of established clinical practice guidelines to manage and optimize care, and an organized approach to performance measurement and improvement activities.

More Information

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Contact the Innovator

Jan Van der Mei RN, MS, ACM
Ambulatory Care Management Director
Sutter Health Sacramento-Sierra Region
(916) 643-6533
Cell: (916) 494-8606
Fax: (916) 503-7543

Innovator Disclosures

Ms. Van der Mei reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

California HealthCare Foundation. Challenging the Status Quo in Chronic Disease Care: Appendix with Detailed Case Studies. Available at:
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

California HealthCare Foundation. Challenging the Status Quo in Chronic Disease Care: Seven Case Studies. Available at:

California HealthCare Foundation. Chronic Disease in California: Facts and Figures. Available at:


1 California HealthCare Foundation. Chronic Disease in California: Facts and Figures. October 2006. Available at:
2 Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1995. Vital Health Stat 10. 1998;(199):1-428. [PubMed]
3 Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004;52(11):1817-25. [PubMed]
4 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. [PubMed] Available at:
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 23, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 30, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.