The Stanford Chronic Care Management System


A Brief Description of the Stanford Chronic Care Management System

The Stanford Chronic Care Management System utilizes telephone triage and followup to manage enrolled patients with established coronary artery disease who experience recurrent cardiovascular symptoms.

The System has 3 key elements:

  1. A training course that enables nurse care managers to establish and maintain telephone contact with enrolled patients. This includes triage and followup of patient-initiated telephone contacts and initiation of routine followup telephone contacts with patients.
  2. An instructional course that permits patients to recognize important symptoms and initiate prompt telephone contact with SCCMS staff.
  3. A database application that permits SCCMS nurse care managers and cardiologists to access patients’ updated electronic medical records on the Web, and to enter data regarding interactions between SCCMS staff and patients and their physicians following patient-initiated telephone contacts. These elements have been developed and tested in actual clinical practice and, with further refinement, can be made available to potential partners through the arrangements described below. Each is part of a package of intellectual property that can be licensed by Stanford University to interested partners.

A key objective of SCRP since the outset has been to understand the clinical environment of the partner organizations in which the research has been conducted. These research studies have been conducted in Academic medical centers, including Stanford Hospital and Clinics; HMO’s including Kaiser Permanente; public hospitals, including Santa Clara Valley Medical Center and San Francisco General Hospital; Veterans Affairs Medical Centers; and private hospitals, including Mills Peninsula Hospital and O’Connor Hospital.

Experience with these diverse medical centers and the distinctive populations they serve has underscored the need to tailor the elements of SCCMS to the needs of partner organizations. The underlying principle of the research has been to specify the many individual steps needed to embed the project into the workflow of the partner’s organization. For example, nurses and others responsible for screening potentially eligible patients are provided with clear-cut criteria for eligibility and a clear understanding of criteria for exclusion. Detailed informational materials specifying the rationale and operation of SCCMS must be provided by nursing staff to patients and their physicians at the outset of the project. Similarly, criteria for describing clinical outcomes such as rehospitalizations and ER visits and the use of medical resources must be provided to hospital-based nurses responsible for obtaining followup data.

To date, the telephone-based intervention has relied on Stanford-based cardiologists and nurse care managers, but a future option is to train these staff members located in partners’ facilities. An important asset in training of these individuals is the nurse training course developed by SCRP. A related objective is for the Stanford-based staff to work with staffs of partners’ facilities over a several-month period to evaluate compliance with the clinical algorithms and protocols developed by SCRP and to tailor these as needed to the needs of the partner. The ongoing clinical collaboration between SCRP and partners’ staff represents a valuable opportunity to make mid-course corrections that enhance the likelihood of long-term adoption of SCCMS by partners.

This unique collaboration provides for clinical oversight and needed tailoring of the clinical algorithms. For example, some partners may provide patients with access to a same-day clinic, while others may refer patients to an urgent care clinic or to a specialized observation unit within the ER.

The ongoing collaboration between SCRP and partners’ staff permits creation of a clinical "dashboard" that clearly depicts the progress of an entire cohort of patients and specifies the individual interactions occurring between SCCMS staff and these patients.


  • How often and when did patients initiate telephone contact with SCCMS?
  • What advice were they provided and what short-term care arrangements did they make (stay at home, visit a same-day clinic, call 911)?
  • When these patients were contacted by SCCMS Operations Staff some months later, what were their clinical outcomes regarding the frequency of ER or same-day clinic visits, rehospitalizations, myocardial infarctions?

Based on these data, a partner is able to determine in scores or hundreds of patients how well the system is operating and whether it is achieving the expected reduction in unnecessary ER visits and rehospitalizations.