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Complex Chronic Conditions

Facing a serious advanced illness is not easy.  There are difficult topics to discuss with your loved ones, treatment options to consider, and tough decisions to make.

Here at Kaiser Permanente, we have a team of health care professionals here help you and your family talk through these challenging issues and understand your options.  We want to hear what is important to you.  Whatever your wishes, we will work with you by providing information and support.

What entails Complex Chronic Conditions?

It is a special program that provides care coordination assistance to people with ongoing health conditions. The case managers will help you manage your conditions so that you can be as healthy and active as possible.

How can we help?

  • Assist elders having difficulty with conditions such as dementia and significant functional impairment
  • A team of medical social worker, a registered nurse, and a pharmacist meet with patient, family and or care giver at clinic for comprehensive evaluations and create health care goals with patient, family, and or care giver.
  • Improve patients’ quality of life and increase their self-care skills when possible
  • Helping reduce unnecessary hospitalizations, emergency department visits, and office visits
  • Optimize patients’ medical management, psycho-social, and functional status
  • Operate as “advice line” to patients in complex chronic conditions program
  • Bridge gap of support before hospice; introducing and discussing hospice as an option to meet end of life goals of care
  • Provide education and assist with life care planning goals

How to get more information?

To learn more about Complex Chronic Conditions, talk to your primary care physician.