Kaiser Permanente San Bernardino County, Chronic Care Management Program Review

Kaiser Permanente San Bernardino County, California, Chronic Care Management Program is a home-based pilot program designed for symptom management, and assistance with community resources for permanently homebound members that are unable to attend routine Primary Care Physician visits. Continuance in the program is based on medical care needs and evaluated periodically. The following cases of this poster demonstrate how physician home health visits serve as a powerful tool in Post-Acute and Long-Term Care (PALTC) practice by enhancing physician-patient relationships, uncovering psychosocial context that could be missed in clinical setting, and facilitating family trust in decision making.