Collaborative Cardiac Care Service: A Multidisciplinary Approach to Caring for Patients with Coronary Artery Disease

Collaborative Cardiac Care Service: A Multidisciplinary Approach to Caring for Patients with Coronary Artery Disease


Brian G Sandhoff, PharmD; Susan Kuca, RN; Jon Rasmussen, PharmD; John A Merenich, MD

Summer 2008 - Volume 12 Number 3


Background: Coronary artery disease (CAD) remains the leading cause of death in the US. In 1996, Kaiser Permanente of Colorado (KPCO) developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD.

Description: CCCS consists of a nursing team (the KP Cardiac Rehabilitation program) and a pharmacy team (the Clinical Pharmacy Cardiac Risk Service). CCCS works collaboratively with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD. Activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events are all coordinated through CCCS. The CCCS uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short- and long-term outcomes.

Outcomes: The CCCS currently follows over 12,000 patients with CAD. The CCCS has demonstrated improvement in surrogate outcomes including: cholesterol screening (55% to 96.3%), the proportion of patients with a goal of low-density lipoprotein cholesterol (LDL-c) <100 mg/dL (22% to 76.9%), and has reduced the average LDL-c to 78.3 mg/dL for the CAD population it follows. The CCCS has shown a reduction in all-cause mortality associated with CAD by 76% in the patients followed by the service. Patient and physician satisfaction have been high with CCCS.

Conclusion: The CCCS coordinates many aspects of cardiac risk reduction care resulting in excellent continuity of care. The CCCS has continued to grow and expand the number of patients enrolled by using innovative strategies and technology and has resulted in excellent care and improved outcomes of the CAD population at KPCO.


27,000 print readers per quarter, 11,225 eTOC readers, and in 2017, 1.5 million page views on TPJ articles in PubMed from a broad international readership.

The Permanente Press

The Permanente Journal (ISSN 1552-5767) is a peer-reviewed journal of medical science, social science in medicine, and medical humanities published quarterly by The Permanente Press.


Physicians may earn up to 1 AMA PRA Category 1 Credit per article for reading and analyzing the designated CME articles published in each edition of TPJ.

ISSN 1552-5775 Copyright © 2018

The Permanente Press. All Rights Reserved.