working with socially and medically complex patients: when ...are circular, overlapping, and...

Working With Socially and MedicallyComplex Patients: When Care TransitionsAre Circular, Overlapping, and ContinualRather Than Linear and FiniteShauna R. Roberts, Jane Crigler, Cristina Ramirez, Deborah Sisco, Gerald L. Early

IntroductionWith the goal of improving health, reducinghospital admissions and cost, and improvingsafety and quality, modern healthcare hasgiven considerable attention to identifyingthe steps needed to successfully transitionpatients from one healthcare setting toanother. Efforts tend to concentrate onpromoting patient/caregiver understandingof the providers’ instructions as to how tomanage their medical conditions, and ad-dressing impediments that inhibit theirability to take suchactions.Theprimary focushas been on the transition from hospital tohome (or other care facility). Models havedescribed what should take place at the timeof hospital discharge and the short timethereafter (Coleman et al., 2004; Naylor andSochalski, 2010; Parry et al., 2003) and Reg-istered Nurses tasked with follow-up on caresteps have been able to demonstrate suc-cess in reducing hospitalization and cost.(Coleman et al., 2004; Naylor et al., 2004).

We found that we needed more for themedically complex patient whose life sit-uations and added social barriers had to beaddressed before they could give attentionto their health. For these patients, a moreintensive care coordination interventionwas necessary if we were to succeed.

Review of the LiteratureRandomized controlled trials have shownsome care transition models to be suc-cessful in reducing rehospitalizations andcost for the patients studied (Colemanet al., 2006; Jack et al., 2009; Naylor et al.,1999, 2004). Other care transition ap-proaches have also shown positive results

(Dedhia et al., 2009; Hansen et al., 2013).The transition of interest in these inter-ventions has been hospital to home orother care facility, and themodels describewhat should take place at the time ofhospital discharge and in the immediatetime thereafter (Coleman et al., 2006;Naylor and Sochalski, 2010; Parry et al.,2003). The care transition interventionshave focused on clinical issues, andadvanced practice nurses often take thelead in carrying them out. Tasks haveincluded educating patients and theircaregivers to assure that they understandtheir medication regimen, can take their

Journal for Healthcare QualityVol. 37, No. 4, pp. 245–265© 2015 National Association forHealthcare Quality

Abstract: The care coordination program described hereevolved from 5 years of trial and learning related to how to bestserve our high-cost, high-utilizing, chronically ill, urban corepatient population. In addition to medical complexity, they havedaily challenges characteristic of persons served by Safety-Nethealth systems. Many have unstable health insurance status.Others have insecure housing. A number of patients havea history of substance use and mental illness. Many have frac-tured social supports. Although some of the best-known caretransition models have been successful in reducing rehospital-izations and cost among patients studied, these models weredeveloped for a relatively high functioning patient populationwith social support. We describe a successful approach targetedat workingwith patients who require amore intense and lengthycare coordination intervention to self-manage and reduce thecost of caring for their medical conditions. Using a diverse teamand a set of replicable processes, we have demonstrated sta-tistically significant reduction in the use of hospital and emer-gency services. Our intervention leverages the strengths andresilience of patients, focuses on trust and self-management,and targets heterogeneous “high-utilizer” patients with medicaland social complexity.

245Vol. 37 No. 4 July/August 2015

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

medications correctly, perform recom-mended self-care steps, and are able tomake and keep medical appointments(Bodenheimer and Berry-Millett, 2009;Coleman et al., 2004; Penn Nursing Ser-vice, 2013).

Although the care transition modelsdiffer in duration and intensity, theyextend 12 weeks or less (Bodenheimerand Berry-Millett, 2009). For example, onefollows patients/families at home post-hospital discharge with 1 home visit and 3phone calls over 2 to 4 weeks, and anotherrequires 2 home visits with more as neededplus at least a weekly phone call for 4 to 12weeks (Coleman et al., 2006; Naylor et al.,1999; Volland et al., 2012–2013). Since staffare continuously adding newly dischargedpatients and completing their time-limitedinvolvement with others, it is not surprisingthat program descriptions do not discusscaseloads or intent to establish longer-termrelationships with discharged patients andtheir families or caregivers.

Some models have aimed at serving thehigh-utilizing medically complex patients.These interventions have been referredto as “comprehensive care coordination,”“coordinated care,” or “care management”(Schraeder et al., 2011), and the PatientProtection and Affordable Care Act, signedinto law in 2009, mentions the concept of“coordinated care” in more than 20 places(U.S. DHHS). Despite this new attention,interventions continue to focus almostentirely on medical and clinical issues. Caretransition models almost never engage staffsuch as social workers and community out-reach personnel whose job is to addresssocial barriers, nor do most comprehensivecare coordination approaches (Boult et al.,2009; Dorr et al., 2006; Peikes et al., 2009).Among the few that do include socialworkers on their interdisciplinary carecoordination teams, most serve the elderlyand are affiliated with health plans(Bodenheimer and Berry-Millett, 2009).Most care transition models have beendeveloped for, and tested with, relativelyhigh functioning patient populations, whoare generally insured through Medicareandoftenhave strong social support systems(Bodenheimer and Berry-Millett, 2009;

Coleman et al., 2004; Dedhia et al., 2009;Parry et al., 2009; Naylor et al., 1999; Richet al., 1995).

An understanding of the profoundeffect of social workers or community out-reach staff to address nonmedical issues inpatients’ lives that impede their ability totake full advantage of medical care is onlynowbeingarticulated. Forexample, just thisyear a debate was initiated regarding thevalue of adding socioeconomic status orother sociodemographic factors into pre-dictive risk models used to assess providerperformance and for public reporting. InMarch 2014, the National Quality Forum(NQF) issued a draft technical reportexploring this topic and asked for com-ments on the merit of pursuing the idea ofadjusting such measures in this way(National Quality Forum, 2014a, 2014b).Simultaneously, two articles were publishedexploring aspects of the same question(Herrin et al., 2014; Nagasako et al., 2014)In addition, a bipartisan bill was introducedin Congress aimed at requiring the Secre-tary of the Department of Health andHuman Services to adjust Medicare andMedicaid’s hospital readmission penalty soas not to penalize hospitals that treatpoorest and most vulnerable citizens(Renacci, 2014).

Complex patients with five or morediagnoses are responsible for .70% ofMedicare healthcare spending and most ofMedicare spendinggrowth since1987canbeattributed to these patients (Bodenheimerand Berry-Millett, 2009). Although it isrecognized that at the time of dischargefrom the hospital different patients canbenefit from different levels of inter-ventions (Bodenheimer and Berry-Millett,2009; Volland et al., 2012–2013), more hasbeen needed to work with patients whoselives are socially, as well as medically,complex. Safety-Net providers often seepatients who have unstable health insur-ance status, insecure housing, fracturedsocial supports, a history of substanceuse and mental illness, and those whoface difficult daily barriers that must beaddressed before they can give attention tomaintaining their health. Patients such asthese need a more intensive intervention

246 Journal for Healthcare Quality


(in content, frequency and duration),which gives equal significance to address-ing their social and medical needs.

Program DescriptionOur care coordination intervention rep-resents the evolution of a program begunin 2009 and, in its current iteration, serveshigh-cost high-utilizing chronically ill pa-tients. It is an adaptation of an acclaimedhigh-utilization team model (Gawande,2011), and we are one of the four sites ina learning network, for which primarytechnical assistance is provided througha school of health policy. (Please see ac-knowledgements and disclaimer).

We are a Midwestern, urban coreSafety-Net health system, and in 2013, weprovided more uncompensated care thanany other hospital in our state. Our systemincludes two acute care hospitals, inpa-tient and outpatient behavioral healthservices, acute inpatient rehabilitation,primary and specialty care practices andclinics, a county health department, anda long-term care facility. We are an aca-demic medical center and serve as theprimary teaching site for schools of medi-cine, nursing, and pharmacy affiliatedwith the University and colocated on ourmain campus. In 2013, we served 110,429unduplicated patients of whom 73,229 werechronically ill. About half of the organ-ization’s patients are of minority racial orethnic origin, 37% are uninsured, 30% arecoveredbyMedicaid, 13%byMedicare,withthe remaining 20%coveredby other payers.We are among the 2% of U.S. hospitals toreceive a Stage7Award from theHealthcareInformation and Management SystemsSociety (both inpatient and ambulatory),representing attainment of the highest levelon the Electronic Medical Records Adop-tion Model. The workflow and patient re-cords of this program are contained withinour integrated inpatient and ambulatorycare electronic health record.

Described herein is an ongoing qualityimprovement program, categorized as nothuman subjects’ research by the AdultHealthSciences InstitutionalReviewBoard.In this program, we are testing concepts

around interventions of intensive carecoordination, with a primary focus ontraining chronic disease patients in both self-management and how to use the healthsystem more wisely. To be eligible for ourcare coordination services, patients must be18 years of age or older, have two hospitaladmissions within the previous 6 months orthree within the previous year, one or morechronicdiseases, andhavebaselinedata for 1year or more available before enrollment.Excluded are those patients whose admis-sions are primarily driven by diagnoses andtreatments for acute oncologic or surgicalcare. Patients are identified through dailyelectronic health record census and read-missions reports, aswell as large retrospectivehealth system data sets. When at all possible,thepatient is introduced to theprogramandoffered enrollment while an inpatient.

Each care team is composed of a HealthCoach Registered Nurse (HC RN) andcommunity-based staff members, whosetitles are Client-Community Liaison (CCL)and Community Health Advocate (CHA).The CCL position was developed for ourhigh-utilizer care coordination program toprovide supportive services and advocate forindividuals as they acquire self-managementskills. Qualifications for the CCL include anassociates’ degree or organized healthcaretraining of at least a year, plus 7 years ofhealthcare experience. The CCL carriesa realized case loadof less than50.TheCHAslive in the communities we serve, have a highschool diploma or General EducationalDevelopment (GED) certificate, and havecompleted Community Health Workertraining through an institution of highereducation. The CCLs and CHAs, known inother programs as Community HealthWorkers, make regular visits, single ortogether, to work with patients’ and theircaregivers/families in the home. Theyobserve and report back to the program’snurses and social workers the patients’ real-life situations that need attention. The CCLsand CHAs receive Medication Aid Trainingoffered through the state’s mental healthdepartment plus our internal training onsafety in the community.

A Licensed Clinical Social Worker(LCSW) serves as Team Leader for the



community portion of the program, andanother LCSW provides intensive casemanagement to a smaller number of pa-tients (,20) who need brief concentratedsupport. In addition, a Psychologist and anAdvanced Practice RN (APRN) have reg-ular points of involvement with our pa-tients. The Psychologist meets newenrollees and counsels about half of themon issues such as depression or anxietyrelated to living and coping with a chronicillness, past adverse experiences, andcoexisting issues. The APRN sees patientsbeing discharged from the hospital who donot have a primary care provider (PCP)and is available for quick access to patientsin the program who are unable to see theirPCP in a timely fashion. The APRN hasa collaborative practice agreement with anInternal Medicine physician.

Staying in contact with our patients iscritically important, but does wax andwane. Our electronic record helps us stayengaged with them by notifying us whenone of our patients registers anywhere inour healthcare system.

Our care coordination intervention in-cludes the following distinct processes: (1)Case Discovery/Triage, (2) Pre-enrollmentassessment, (3) Enrollment and FirstHomeVisit, (4) Care Coordination (addressingboth medical and social issues), (6) CarePlanning (Care Plan developed within 30days of enrollment; updated thereafter),(6) Graduation, and (7) Check back toassess maintenance of desired behaviors.

We have developed two assessment andeducation tools for our program that arecritical to our care coordination work. TheGuided Chronic Care Social Intake Naviga-tion Guide (SING) (Figure 1) helps deter-mine patient attributes and stimulatesinitiation of the Care Plan (Figure 2), whichlists themilestones the patient needs tomeetto be able to self-manage their medical con-dition(s). The Care Plan is used to introducethe patient to the navigation measuresneeded for self-management and containsmedical and social criteria for graduation aswell as a planning section to address behav-ioral and substance abuse issues. Care stepsthat meet best practice guidelines for man-agement of the individual’s major chronic

disease diagnoses are identified and ad-dressed within the plan, as are the personalgoals outlined by the patient. The individu-alized Care Plan is developed within 30 daysof enrollment and refined during the teams’interventions going forward; the navigationskills are reviewed and discussed until thepatient can “teach back” what is required forself-management. The SING uses the pa-tient’s housing situation as a point of depar-ture for learning each patient’s uniquecircumstancesand identifyingareas for initialattention by the team. Demonstration ofthese behaviors is used to determine readi-ness for phased steps toward graduation.

In addition to these instruments, theelectronic Medication Record form,although not unique to our program, isimportant. TheMedication Record is usedto record the number of refills remainingand the need for prescription renewal.Several members of the team are involvedin understanding medications, includingthe CCLs and CHAs. On the first homevisit, they observe the medications thepatient has in the home and record whatthe patient reports they are taking. Theypass this information back to the HC RNfor review and reconciliation with what isprescribed. The HC RN can then counseland educate the patient about the medi-cations and communicate with the pa-tient’s PCP if clarification, refills, or newprescriptions are needed.

Study Design and MethodsIn this program, we are exploring andtesting the use of intensive resources tochange behavior in the way a small groupof high-cost patients with chronic disease(s) use the health system. The outcomes ofinterest include improved use of resourcesby reducing charges and cost for hospitaladmissions and emergency department(ED) visits. The goal of our high-utilizerintervention is to teach patients to self-manage their medical conditions andthen “graduate” them into a primary caresetting with an understanding of how toeffectively navigate the healthcare system.

Project effectiveness for resource utili-zation is assessed by measuring the



number of ED visits, number of inpatientadmissions, and those total charges duringthe previous year and for the variableperiod after enrollment. Patient chargesare used as an indicator of “costs,” even ifimperfect (and even though our chargestend to be the lowest in the community),because charges reflect the standard hos-pital pricing of services before adjustmentsthat occur at varying rates according to thepayer. Cost to charge ratio is monitored inthe absence of cost accounting.

Patients are continually enrolled atdifferent times, resulting in differentlengths in the post-enrollment time frame.Patient diagnoses that are driving admis-sions, and their burden of coexistingchronic diseases, are heterogeneous. The

natural history of these common chronicdiseases is such that the patients have ever-evolving health conditions intermixedwith periods of disease decompensation.

Length of time in the intensive inter-vention period is variable and determinedby demonstrated need and functionality:socially, medically, and behaviorally. Ourintervention is not administered by numberof days exposed but instead is administereduntil the patient demonstrates the behaviorcriteria we have defined (“graduates”), thepatient expires, or transitions. Because thepatients are graduated according to dem-onstration of objective self-managementbehaviors (Figure 2), the resultant post-graduation time frames are also variable. Asmall number of patients are transitioned to

Figure 1. The Guided Chronic Care Social Intake Navigation Guide is used as anassessment of the patient’s housing and social circumstances at enrollment.Care coordination efforts are considerably less successful if barriers in theseareas are not effectively addressed.

Guided Chronic Care: Social Intake Navigation GuideCheck when Complete

Homeless Check when

Complete

Housing / No Social Supports Check when

Complete

Housing and Social Supports

ID; Social security card, birth certificate, DDS-14, insurance card, driver’s license

Check all issues for homeless Check all issues for homeless and housing w/o supports

Income, disability, budgeting Establish amount of self-care Ptcan complete alone and areas of assistance needed.

Examine condition of support system (stable/healthy/functioning)

Medication Review/planning/costs

Budgeting (Communicate that rent, utilities, meds and nutrition come first.)

Assess and work on plan toestablish formal / informal supports

Housing /conversation regarding housing history

Medicaid approved transportation and supporting forms

Chronic Disease Self Management (Stanford) class for Patient and support

Relationship dynamics (questioning for supports)



Contact Information / plan Encourage Pt to maintain appointment(s) with PCP, Specialty doctor or Nurse Practitioner

Encourage Patient to maintain appointment with PCP, Specialty doctor or Nurse Practitioner

Enrollment at bedside if no phone

Assess and work on plan to establish formal/informal supports

Modeling self-management skills with Patient and social support

Encourage Pt to keepappointment with PCP, Specialty doctor or Nurse Practitioner

Chronic Disease Self Management (Stanford) class for Patient and support

Modeling and teaching healthy boundaries

Assess and work on plan to establish formal/informal supports

Teach Pt and support how to self-advocate (Teach Back)

Teach Patient and support how to self-advocate (Teach Back)

CCL completes follow up phone calls and file checks post –graduation

CCL completes follow-up phone calls and file checks post –graduation

CCL completes follow up phone calls and file checks post –graduation



othercare settings fora varietyof reasons, forexample, residential care or absence ofreadiness to engage in self-management.Variable intensity of follow-up occurs post-graduation, according to need, and somepatients have periods where partial teamsupport is resumed. Criteria are in devel-opment for when the team should resumesupport and for what period of time. All

enrolled patients continue to be trackedover time.

To make like comparisons and monitorresource use and cost data in short inter-vals, our major metrics are calculated asper 30-day averages per patient, across theyear before and the time since enrollmentfor each patient. With this method, thesignificance of the intervention can be

Figure 2. The Guided Chronic Care Plan is used to assess and teach self-navigation skillsneeded for graduation and contains best practice disease management caresteps for the patient’s chronic conditions.

Guided Chronic Care Plan

Demographic/Background information:

Identified Strengths:

Social Supports:

Health Criteria For Graduation

Yes No Date Mastered

Barriers / Comments

Action Step Date Completed

Keeps 75% of appointments Knows/demonstrates how to schedule appointments Knows/demonstrates names and reasons of all their prescribed medicationKeeps logs (blood pressure, blood sugar, etc.)Brings a list of questions for the doctor to appointments / asks questionsBrings medications or updated medication list to appointmentsKnows/demonstrates how to refill medications, and maintains adequate supply of all prescribed medicationKnows/demonstrates primary medical diagnosis, and basic treatment/maintenance, knowledge thereofPatient Goal(s) and Action/Step(s) to achieve:

Disease Specific Care Steps inserted here (chronic disease management measurable care steps matching patient diagnoses):



assessed at intervals for each individualpatient and for the overall program. Eachpatient serves as their own control byusing a 1-year baseline of utilization pre-enrollment to compare with utilizationafter enrollment. Interval assessment ofresults allows us to be responsive tofindingsand make process refinements toward bet-ter quality of care or best use of resourceinvestment in the care management strat-egies. Patients with a year or more sinceenrollment are analyzed as a segment ofparticular interest, because their utilization

may be more reflective of the longer-termprogram outcomes. Annualized data arealso tracked, but with caution, because thisheterogeneous population has ongoingchanges in their medical and social condi-tion. Statistical Analysis System (SAS)paired t-test is used for these before–aftercomparisons.

ResultsWe have enrolled 198 patients: 86 havegraduated and 43 are now 1 year or more

Figure 2. Continued.

Social Criteria for Graduation


Barriers /Comments


Transportation (knows/demonstrates use of transportation to get to and from appointments) Food (knows/demonstrates skills to maintain adequate nutrition)Shelter (knows/demonstrates skills to maintain adequate housing)Communication (knows/demonstrates how to contact needed members of health care team) Patient uses Teach-Back to assess understanding during appointmentsPatient Goal(s) and Action/Step(s) to achieve:

Behavioral/ Substance Abuse Criteria For Graduation


Barriers / Comments


Patient has resources/referrals to appropriate programs Patient Goal(s) and Action Step(s) to achieve:

Additional / Summary Comments:

Signature Role DatePatient

Health CoachCCLCHA



after enrollment. The mean number ofchronic disease diagnoses per patient is4.98, SD 2.18, and amedian of 5.More thanone third of the patients enrolled have sixor more chronic disease diagnoses.

Patient complexity is reflected by thecharacteristics in Table 1. A total of 17patients have died, which is not unex-pected considering the natural history oftheir chronic diseases and their underlyingsocial complexities.

Table 2 displays descriptive statistics ofthe 30-day averages of hospital utilizationfor inpatient admissions, ED visits, andthose patient charges before and afterprogram enrollment. In this intervalanalysis of the 198 patients enrolled fordifferent time periods, the results dem-onstrate statistically significant reductionin post-enrollment resource use. A corre-sponding rise in clinic visits is a positiveoutcome because the goal was to shift thecare of these patients into continuitythrough connection to the PCP and awayfrom episodic interactions with ED andhospital inpatient providers (Table 3).

Persistent reduction in resource utiliza-tion is demonstrated in the subgroup of 43patients for whom.1-year post-enrollmentdata are available to compare to thebaselineyear of pre-enrollment data. Statisticallysignificant improvements for these 43 pa-tients include a reduction in hospitaladmissions from a mean of 0.56 per 30 daysor 6.7 admissions per person per year to0.3 per 30 days or 3.6 admissions per personper year. The reduction inEDvisits for thesepatients decreased from a mean of 1.55 per30 days or 18.6 ED visits per person per yearto 0.7 per 30 days or 8.4 ED visits per personper year. The reduction in chargesdecreased from a mean of $110,601 to$57,038 per person per year. Total chargereduction was $2,303,209 when comparingthe year before to the year after enrollment.The actual cost reduction for this group ofpatients when comparing the year beforeand after enrollment was $1,451,021.67 or$33,745 per person per year, when cost tocharge ratio was applied (63%) to the dif-ference of $53,563. Table 4 demonstratesthis analysis in the same format of per 30-dayaverages as the tables showing the totalnumber of patients enrolled and Table 5shows their clinic visits.

Annualized improvements demon-strated so far for the 198 patients enrolledinclude reduction of 283 hospital admis-sions and 845 ED visits. The mean chargesof $78,740.91 per person or an annualizedtotal of $15,590,700.18 pre-enrollment tomean charges of $54,198.64 per person oran annualized total of $10,731,330.72 issignificant (p , .001, Table 6). Note that

Table 1. Guided Chronic Care: PatientCharacteristics

N (%)

GenderFemale 101 (51%)Male 97 (49%)

AgeMean 55.83 years (SD 11.54)Range 24–84 years

Stated raceBlack 146 (74%)White 48 (24%)American Indian 1 (0.005%)Other 1 (0.005%)Prefer not to say 1 (0.005%)

Chronic conditionsMean 4.98 (SD 2.18)Range 1–13

HousingHouse/apartment/room 148 (75%)Shelter 19 (10%)With friend or relative 19 (10%)Street/abandoned home 3 (2%)Other 8 (4%)

InsuranceMedicaid 102 (52%)Medicare 82 (41%)Uninsured 13 (7%)Commercial 1 (,1%)

EducationCompleted grades 6–8 13 (7%)Completed grades 9–12 63 (32%)High school diploma/GED 55 (28%)Some College/Associates degree 32 (16%)Bachelor’s or other degree 12 (6%)Unsure or prefer not to say 16 (8%)

Abbreviation: GED, General Educational Development.



annualized clinic charges did not increasesignificantly during this time period forthese patients (Table 7).

The annualized savings in charges foradmissions and ED visits is $4,859,369.46and with an applied 63% cost to chargeratio would be stated as annualized costreduction of $3,061,402.76. However, costreduction would need to be restated by thepayer. For example, in cases where thepatient had no healthcare coverage andwhose cost of care was a burden for thehealthcare system, these calculations wouldbe restated as cost avoidance for the healthsystem. If this program were not funded byan award, the cost of the program would

then need to be subtracted from theannualized cost reduction as well. Forcases with an allowable or contract pay-ment, the cost to the payer would be ex-pressed as the allowable amount and thecost and margin for the health systemrecalculated accordingly. These areimportant considerations because thisprogram is staff-time intensive.

Length of stay for the 198 patients was4,525 admitted days before enrollmentwith a mean of 0.87 (SD 3.12) and medianof 0. After enrollment, there were 3,245admitted days with a mean of 0.84 (SD3.84), a median and interquartile range of0, and a p of .0107.

Table 3. Descriptive Pre- to Post-Enrollment Clinic UtilizationStatistics*

N†

Before Enrollment‡ After Enrollment§

pMean (SD) Mean (SD)

Clinic visits 198 1.24 (1.12) 1.62 (2.01) .0088Chargesk 198 $848.05 ($1333.27) $846.77 ($1599.15) .9925*Since patients were enrolled at different times, they had differing lengths of

post-enrollment time frames, ranging from 30 to 512 days; median 245 days. Forcomparison, pre- to post-enrollment resource use outcomes were adjusted toreflect the 30-day averages per patient.

†N = patients enrolled through March 31, 2014.‡Before enrollment—1 year before enrollment date of each patient, ending the day

before enrollment.§After enrollment—starting with enrollment date and ending April 30, 2014.kCost to charge ratio 63%: does not represent total healthcare spend.

Table 2. Descriptive Pre- to Post-Enrollment Hospital Utilization Statistics*

N†


% Improvement pMean (SD) Mean (SD)

Inpatient admissions 198 0.37 (0.32) 0.25 (0.34) 32% ,.0001ED visits 198 0.89 (1.37) 0.53 (0.98) 40% ,.0001Charges: admissions and EDk 198 $6,561.74 ($5,287.61) $4,516.55 ($6,506.66) 31% .002*Since patients were enrolled at different times, they had differing lengths of post-enrollment time frames,

ranging from 30 to 512 days; median 245 days. For comparison, pre- to post-enrollment resource useoutcomes were adjusted to reflect the 30-day averages per patient.

†N = patients enrolled through March 31, 2014.‡Before enrollment—1 year before enrollment date of each patient, ending the day before enrollment.§After enrollment—starting with enrollment date and ending April 30, 2014.kCost to charge ratio 63%: does not represent total healthcare spend.Abbreviation: ED, emergency department.



Data from the Guided Chronic Care Planare not yet refined to differentiate responsesby discreet fields versus free text commentand thus not yet available for results report-ing. Data from the actions taken bycare managers on disease management bestpractice care stepswithin theGuidedChronicCare Plan are also not yet available. The dis-ease management module data will be mea-sured both by care manager actions takenand chronic disease registry metrics, whichare in the early stages of deployment withinour electronic health record.

Despite the statistically significant re-ductions after intervention, some of theresults impact is best relayed by a patientstory:

Jim is a 63-year-oldAfricaAmericanwithdiagnoses of hypertension, asthma, anti-social personality disorder, bipolar dis-order, and anxiety. He has a history ofsubstance abuse and trauma froma gunshot wound. He was estrangedfrom his family and lived in a shelter.The team, including the psychologist,quickly established rapport with him

Table 4. Descriptive Pre- to Post-Hospital Utilization Statistics for Patients 1 Year orMorePost-Enrollment*

N†



Inpatient admissions 43 0.56 (0.50) 0.30 (0.36) 46% .0006ED visits 43 1.55 (2.33) 0.70 (1.07) 55% .0029Charges: admissions and EDk 43 $9,216.76 ($7,755.93) $4,753.19 ($4,788.87) 48% .0002*Since patients were enrolled at different times, they had differing lengths of post-enrollment time frames,

ranging from 399 to 512 days; median 447 days. For comparison, pre- to post-enrollment resource useoutcomes were adjusted to reflect the 30-day averages per patient. Only patients with at least 1 year of timepost-enrollment were included in this segment of the resource analysis.

†N = patients enrolled between December 1, 2012, and March 31, 2013.‡Before enrollment—1 year before enrollment date of each patient, ending the day before enrollment.§After enrollment—starting with enrollment date and ending April 30, 2014.kCost to charge ratio 63%: does not represent total healthcare spend.Abbreviation: ED, emergency department.

Table 5. Descriptive Pre- to Post-Clinic Utilization Statistics forPatients 1 Year or More Post-Enrollment*

N†



Clinic visits 43 1.15 (1.37) 0.96 (0.93) 16.52% .2032Charges 43 967.55 ($1,721.30) 503.73 ($542.84) 47.94% .0524*Since patients were enrolled at different times, they had differing lengths of post-

enrollment time frames, ranging from 399 to 512 days; median 447 days. Forcomparison, pre- to post-resource use outcomes were adjusted to reflect 30-dayaverages per patient. Only patients with at least 1 year of time post-enrollmentwere included in this segment of the resource analysis.

†N = patients enrolled between December 1, 2012, and March 31, 2013.‡Before enrollment—1 year before enrollment date of each patient, ending the day

before enrollment.§After enrollment—starting with enrollment date and ending April 30, 2014.kCost to charge ratio: does not represent total healthcare spend.



and while the Health Coach workedwith Jim on medical issues, the socialworker assisted him in securing housingand re-establishing a relationship withhis daughter. The Community ClientLiaison and Community Health Advo-cate provided social support. All mem-bers of the teamwere available to Jim byphone and in person to listen and tooffer support andencouragementwhenhe expressed frustration and discour-agement. He was open to change andworked productively with the team.Jim now takes initiative for his own careand continues to work withthe psychologist. He is drug andtobacco free, and he and his daughterlive together in an apartment. They

recently attended a ceremony cele-brating his graduation from theprogram the same week his daughtergraduated from high school. Heremains in contact with the team andrecently signed up for a nutrition classat the hospital. His mean 30-day inpa-tient admissions, ED visits, and chargesalso showed marked improvement.Annualized admissions decreased from3.12 to 0, ED visits decreased from 8.28to 0, and aggregated charges decreasedfrom $37,884 to 0 to date. Not only wasJim’s personal response gratifying, butafter 241 days of being engaged in theprogram, his high utilization ofhealthcare resources was markedlyreduced.

Table 6. Descriptive Pre- to Post-Annualized Hospital Utilization Statistics*

Annualized N†



Inpatient admissions 198 4.46 (3.78) 3.02 (4.03) 32% ,.001ED visits 198 10.66 (16.43) 6.39 (11.72) 40% ,.001Charges: admissionsand ED visits

198 $78,740.91 (63,451.27) $54,198.64 ($78,079.93) 31% .0002

*Since patients were enrolled at different times, they had differing lengths of post-enrollment time frames,ranging from 30 to 512 days; median 246 days. For comparison, resource use outcomes were adjusted toreflect 30-day averages per patient then annualized (multiplied by 12).

†N = patients enrolled between December 1, 2012, and March 31, 2013.‡Before enrollment—1 year prior to enrollment date of each patient, ending the day before enrollment.§After enrollment—starting with enrollment date and ending April 30, 2015.kCost to charge ratio: does not represent total healthcare spend.Abbreviation: ED, emergency department.

Table 7. Descriptive Pre- to Post-Annualized Clinic Utilization Statistics*

N†



Clinic visits 198 14.94 (13.40) 19.41 (24.12) 29% .0088Chargesk 198 $10,176.61 (15,999.29) $10,161.20 (19,189.76) 0.15% .9925*Since patients were enrolled at different times, they had differing post-enrollment time frames, ranging from

30 to 512 days; median 246 days. For comparison, pre- to post-resource use outcomes were adjusted toreflect 30-day averages per patient then annualized (multiplied by 12).

†N = patients enrolled between December 1, 2012, and March 31, 2013.‡Before enrollment—1 year before enrollment date of each patient, ending the day before enrollment.§After enrollment—starting with enrollment date and ending April 30, 2015.kCost to charge ratio: does not represent total healthcare spend.



DiscussionThe complexity and combination of med-ical conditions and life situations in thispatient group is the major reason why theyultimately benefit from this intensive carecoordination approach. As we demon-strated in a previous article, although theyare very sick, these patients remain sur-prisingly functional despite their illness(s)(Roberts et al., 2012). Additional importantgeneral observations include the following:these individuals are very resilient, highlyresourceful, and are extraordinarily patientwith the healthcare system. At enrollment,many are overwhelmed; disengaged; non-trusting; and lacking in a feeling of self-worth or deserving of services (making itcritical to have psychology expertise inte-grated into the team structure). Further-more, this patient group wants to beperceived as agreeable (e.g.,may know theywill be unable to keep their next appoint-ment for some reason but would not offerthat unless asked).

Care transitions are normally linearand finite (e.g., from Provider A to Pro-vider B), but in our care coordinationprograms, the number and nature of caretransitions are circular, overlapping, andcontinual. They involve cross-sectoral caregivers including social services, govern-ment workers, and church and commu-nity members—in addition to medical,social work, and behavioral health pro-viders in one ormore health systems—andthey take place at multiple locations.Because the interventions need to be tai-lored to eachpatient individually, basedontheir medical and life situations, they arenot predictable at the outset, and “modelfidelity,” as required by most care transi-tion models, is not feasible.

Patients in this quality improvementprogram tend to be younger than thosetargeted by previously described caretransition models and many have unstablehealth insurance, a history of substanceuse, and significant mental illness. Nearlyall are from socially disadvantaged com-munities plagued by poor health status,and low literacy is common. Many arestruggling with difficult life circumstances

such as an alarming number have beenemotionally or physically traumatized;some have no income while others haveincome that it is insufficient to meet basicsurvival needsmaking it challenging to payeven minimal co-pays for prescriptions;many live in unstable housing or in dan-gerous neighborhoods; and many haveinadequate, or no, family and social sup-port systems. At enrollment, the conceptof self-management is not familiar to mostof them.

Systems, like the Housing Authority,Medicaid, and health systems, often add totheir burden. Examples include applica-tions for benefits are frequently difficult tofigure out and time consuming to file,applicants often feel disrespected or trea-ted as if they were helpless, and agencystaff are often not adequately sensitive toclient issues regarding low/no literacy. Inaddition, for non-English speaking, trans-lation services can be inadequate, culturalcompetency is a problem, and mailedannual reapplication notices (such asfor Medicaid) are difficult to recognizeas something official and may bedisregarded.

Despite all this, with our teamapproach, many program participantshave been successful in learning andapplying the skills needed to self-managetheir condition(s). Some of the principlesunderpinning our care coordinationintervention include (1) our work withpatients is strength based, meaning welook for the strengths each patient bringto the encounters and build on thesewhen partnering with them in settinggoals and tracking progress. Although thestrength perspective is a classic tenet ofsocial work thought (Cohen, 1999;Saleebey, 1996) and is regularly used insocial work practice, we have found thisorientation to be uncommon among otherpractitioners, who often look for deficitswhen engaging with patients. Also, mostassessment tools focus on identifyingpatient/client deficits, prompting us tomodify these tools to strength-based foruse in our programs. (2) Establishing trustrelationships between team members andthe patients with whom they are working is



essential in empowering patients to self-manage their medical conditions. (3) Anystep patients take toward self-managementis important, and we recognize that com-peting priorities in patients’ lives mustoften be addressed alongside thework theydo with us. (4) Every member of thismultidisciplinary team is challenged to behighly adaptable as traditional rolesoftentimes need to be supplemented byother responsibilities not normally asked oftheir discipline. Intense care managementrequires critical thinking and skills thatexceed what is taught in traditional healthprofessional programs (Bodenheimer andBerry-Millett, 2009).

There are similarities between our carecoordination intervention and others’care transition interventions, including(1) typically serve adult populations, (2)engagement generally starts with patientsduring a hospital stay and focuses on thetransition at hospital discharge, (3) anemphasis on patient involvement in goalsetting, (4) the necessity of care plans (butours are developed over a period of time asthe patient engages in the program,whereas other programs develop these atthe time of hospital discharge), (5) follow-up home visits, (6) a follow-up appoint-ment with a PCP at hospital discharge, (7)Information Technology support, and (8)recognition that telephonic follow-upalone is not enough.

There are also differences: care transi-tion approaches usually offer “models”and require adherence to the models(Coleman, 2007), whereas our care coor-dination intervention is more accuratelydescribed as a framework or set of pro-cesses focused on changing behavior,rather than a model.

The usual care transition interventionsinvolve fewer interactions between theteam and the patients, whereas our carecoordination process involves a largenumber of team/patient interactions overmore than 8 weeks, with that timeextended until patients are able to dem-onstrate behaviors required to “graduate.”We see building of trust and assuring thatpatients are taking medications as pre-scribed, among our greatest impact steps,

and achieving these outcomes cannot beaccomplished in a shorter interventionwindow. Patient self-management is a goalof both the care transition and care coor-dination interventions, but it is the cen-terpiece of every interaction our carecoordination team has with patients, andwe have spent considerable time articu-lating what is required to achieve this. Thisdifference seems related to the charac-teristics of the patient populations served.Many of the patients served throughusual care transition programs seemto need limited support to acquireself-management skills. However, self-management is a new concept to most ofour patients, and it needs to bemodeled tobe understood while simultaneously ad-dressing the significant socioeconomicand other challenges to achieving it. Ouremphasis on trust and relationship build-ing between the teams and participantsdoes not seem reflected in literaturedescribing the care transition models.Here, too, the populations served may bea factor.

Our teams focus on both medical andsocial issues and understanding and build-ing the capabilities needed to self-managein both arenas, and our teams require socialworkers and community-based staff becauseof the frequent dominating effect of socialissues. Our focus on serving the patientwhile they are attending an appointmentand working in the space between providerencounters minimizes requests for patientstomake extra trips to the healthcare system.This is particularly important for ourpatient group as they frequently have lim-ited access to transportation, complicatedby limited phone minutes or changingphone numbers and addresses.

Our teams are larger, more diverse, andcarry smaller caseloads than those used bymedical care transition interventions. Ourprogram builds on quality improvementprograms we have had underway since2009 to better serve our chronic care pa-tients as described in the Journal forHealthcare Quality (Roberts et al., 2012).Wealso participate in the state’s MedicaidHealth Home program, established underSection 2703 of the Affordable Care Act



allowing states to provide care coordina-tion services for chronically ill Medicaidbeneficiaries. These programs coupledwith our long history of disease manage-ment efforts have provided uswith valuableunderstanding regarding the spectrum ofcare coordination needs and the in-dications for intensive care management.

The uniqueness of the complexity foreach individual patient in this programcreates many confounding variables, andbecause only the very high–cost patientsare eligible, the samples sizes are small.This care coordination intervention is verylabor intensive and thus costly itself, mak-ing assessment of ongoing effectivenessessential. Our method for analyzing carecoordination outcomes allows intervalcomparison of pre/post-enrollment re-sults in an individual chronic diseasepatient or aggregate patient population,with variable times of program entranceand lengths of time to graduation. Ongo-ing assessment and quarterly data moni-toring is used to guide course correctionand program refinements. Subgroupanalyses such as those patients enrolled1 year or more as well as annualized datafor the entire group provide additionalperspective that is helpful.

Limitations, Challenges, and LessonsLearnedLimitations of this program are the shortduration, lack of access to total healthcarespend data from other institutions, lack ofrandomization, and small sample size ofthe patients enrolled, although high-intensity care management is only appli-cable to a small percentage of our patientpopulation.

Challenges include the complexity ofthe patient group we focus on, whichforces us to evolve in response to lessonslearned. The workforce developmentportion of this program is particularlychallenging and a few key learnings areoutlined here. We underestimated thechallenges faced by this multidisciplinaryteam. In our earlier care coordination in-itiatives, we observed that the RNs andLCSWs were needed for a number of roles

and responsibilities that are nontra-ditional for their professions. Althoughissues of a medical nature were chieflyaddressed by the RN and issues of a socialnature were primarily the responsibility ofthe LCSW, considerable coordinationbetween the teammembers was needed toassure an effective approach in workingwith these medically and socially complexpatients. More recently, we realized thatbeyond role definition, the RN and LCSWpositions lacked the usual structure that ischaracteristic of most nursing and socialwork positions in health systems and(while in the development stage) wereconstantly evolving. The commitment toworking as a part of a team was also dif-ferent because staff are asked to rely onexpertise and support from team mem-bers of other disciplines.

Early on, we determined that certaintasks the HC RNs and LCSWs were per-forming could be offloaded as these didnot require their level of licensure, train-ing, and skill. By doing so, we could free upthe HC RNs and LCSWs to serve morepatients and increase their job satisfaction.To address this, we worked with the teamsto identify tasks that could be done byhigh functioning Administrative Assistants(AAs) and we now use AAs for tasks such asmaintaining telephone contact with pa-tients to remind them of appointments,check up on them when they have notbeen heard from, and assist the teammembers in entering and retrieving datarelated to the patients they serve. This iseffective as long as there are intermittentface to face opportunities for the patientswith the HC RNs, LCSWs, and CCLs.

From the outset, we were convincedthat we wanted to incorporate membersof the community on our care coordina-tion teams believing in the value peersupport has been shown to bring to thistype of work. To this end, we worked witha community coalition and the localcommunity college to develop a Commu-nity Health Worker training program.We have recruited individuals fromthe training program and call this role inour program CHA’s. They often serveas a bridge between the patients, their



supports such as family and friends, andthe hospital personnel. The CHA’s advo-cate for and assist patients with navigatingboth the healthcare system and the sys-tems of care within the community. Apatient, who cannot read, for instance,may have a CHA go with them to fill outpaperwork at the Social Security office. ACHA may know the best place in the localcommunity to find a used couch forsomeone or which food pantry is closest toa patient’s home.However, we have foundthat expecting CHA’s to be able to com-plete many hospital environment tasks isprobably not reasonable. For example,the CHA’s have consistently had difficultywith computer skills (including schedul-ing, calendar maintenance, and docu-mentation). Extensive and ongoingtraining regarding basic office and orga-nizational skills has been necessary alongwith reconfiguration of job expectations.The strength of the CHA is in establishingrelationships through face to face inter-actions and assisting in addressing thesocial barriers for our patients. OurCHA’s provide perspectives in huddlesthat often enlighten licensed staff andoffer a better understanding for the teamregarding the unique needs of the pa-tients we serve.

We also developed a position which isunique to our program called ClientCommunity Liaisons; these individualsare extenders of the LCSW in the com-munity and are crucial to success. Theyspend their time meeting patients wherethey live: in their homes, in shelters, atrestaurants, libraries, and any number ofother places in the community. They arethe frontline contact between the healthsystem and the patient, working to assistpatients with both the physical and socialbarriers to health. The CCLs may assistpatients in filling out paperwork to applyfor disability, take patients shopping tomodel appropriate food choices at thegrocery, and help a homeless patient findhousing or any number of tasks thathinder the patient’s ability to managetheir health. Working in collaborationwith the Health Coach, they may deliverblood pressure cuffs or logs and check

medication lists against what the HC RNreports should be in the home.

Key to the success of the work of theCCL is the ability to establish trusting re-lationships with patients, their families,and other caregivers. Many of the highutilizers of Safety-Net hospitals live notonly with the challenges surroundingmultiple chronic diseases but also withpoverty, mental illness, and chaotic lifecircumstances. The CCLs must under-stand the context of the lives of their pa-tients and accept those individuals wherethey are. It is crucial to the CCL’s successthat we hire those with an aptitudefor ongoing professional developmentregarding effective interactions with pa-tients and dealing with their barriers toself-management.

With CCLs and CHAs, their supervisorsmust be mentors and a means of support.The CCLs and CHAs often find them-selves face to face with the graphicallydifficult living conditions of many of ourpatients and each interaction and patientexperience is unique. The staff need tofeel safe enough with their supervisors andteam colleagues to discuss and process theexperience, to prevent burnout.

A final observation about our diversemultidisciplinary team is that, to be suc-cessful, we need to pay considerableattention to supporting the team’s devel-opment. Team members come from dif-ferent work cultures where distinctiveterminology and concepts are used andshorthand and acronyms are common.Professionals working within the walls ofthe hospital may at times be untrusting ornot quite understand the role of thecommunity staff in actually doing theirwork “on the streets,” and there may bemistrust of other team member’s frame ofreference. The “lens” through which eachsees this work results in different priorities,requiring consistency and transparency incommunication to mitigate conflict.

There are pragmatic aspects to theteam development needs as well. Forexample, we found that many of our pa-tients have substance abuse issues and thataddictions were often a barrier to care.The staff needed training in substance



abuse counseling, and this is being incor-porated in our ongoing work and trainingplan.

Implications for PracticePopulation management approaches arebeing implemented nationally, and carecoordination has a valuable place in them.As we previously described, it is importantto recognize that not everyone needs carecoordination. We approach this by pro-filing patients in quadrants by burden ofchronic medical conditions. There isa spectrum of disease and social com-plexity that benefit from different levels ofcare coordination intensity. Throughevolving understanding, we can learn howmuch cost investment for intensive carecoordination is warranted to yield clinicaland financial effectiveness (Roberts et al.,2012; Figure. 2). Although it can be aug-mented by Information Technology, carecoordination is resource intensive andmust be carefully applied to both improvequality and reduce cost. We describea successful approach of intensive indi-vidualized care management for a smallgroup of high-cost chronic disease pa-tients. Carefully applied, the cost of theintervention is worthwhile and yields sig-nificant savings.

The high cost of healthcare and itscontinuing increase is a major social andeconomic force and increasingly a lifeeffector for all of us. If we can learn howto provide useful quality care for thosewith extremely high medical and socialneeds and more effectively manage theircost challenges, we can help to impact theupward cost spiral. Furthermore as Med-icaid is transformed, adding newlyinsured beneficiaries with social com-plexity and value-based purchasing seeksproviders who can address issues thatimpede patients’ abilities to take full useof the health system, payers will look tothose who have developed successful ap-proaches for serving these challengingpopulations. If we can improve our effi-ciency of care for those with greaterneeds, we can also expect to transitionsome of the best practices and lessons

learned to other less-intensive segmentsof the patient population.

Directions for Future ResearchIt will be important to continue tostreamline our program methodology,further improve its efficiency, and evolvein our understanding of the essentialintervention components that are ofhighest impact. Defining which inter-ventions are most critical to obtaining ourresults would have considerable value.Delineation of the most impactfulresource investment for each level of caremanagement complexity is needed (e.g.,at what complexity is there cost and qualitybenefit of care coordination and for whatprofile of high complexity patients is itimpactful to have smaller case loads thatlead to more effective care managementas return on investment). Learning thesethings will in turn help us understand howto further decrease the cost of the inter-ventions and/or to apply them moreselectively. These are important consid-erations because this program is staff-timeintensive and the indication for this levelof intervention is applicable to only a smallgroup of patients. Ultimately, we need tolearn to identify those at risk for becominghigh-cost high-utilization chronic diseasepatients and design earlier interventionsthat prevent cost escalation.

Additional studies should include qual-itative evaluation of the life improvementand reduction in burden of treatmentassociated with the interventions. Contin-ued evolution in understanding the mea-surable quality of clinical outcomes thatresult in this type of care intervention isessential, because there are both clinicaland cost benefits to systematic incorpora-tion of disease management into intensivecare coordination programs. Analyzing themeasurable disease management impactand using standard finance methods fortracking return on investment in carecoordination will be needed if this type ofwork is to be sustainable.

Our future analyses should also includecomparison of patients enrolled whostay engaged with those who do not.



Additional understanding is needed of thepostgraduation period, and results changeover time. It would be valuable to moreclearly define the monitoring needed, in-dications to reintervene with support, andthe effectiveness of reintervention, forthose whose cost and utilization aretrending back up after graduation. Addi-tionally, we need to continue to separatelyanalyze and learn from that small butgrowing group of patients who have atleast 1 year of post-enrollment data.

Further evaluation is also neededto answer overarching cost-effectivenessquestions “How many dollars does it costto save the dollars identified?” But, per-haps the most difficult questions will turnout to be societal or even political andinclude: “What’s it worth to address thehealthcare needs of the high utilizers?”

SummaryTransitioning from inpatient to outpatientcare is a difficult and blurred step for thehigh utilizer. We are evolving a replicableprogram that can help, when selectivelyapplied. It has at its core a growingawareness of the patient and theirstrengths, the individual’s needs and theirbarriers to care and self-management, anda transition of care that entails a pro-grammatic intervention of an unusuallydesigned and coordinated multidisciplin-ary team. The early results show significantreductions: 32% decrease in admissions,a 40% reduction in ED visits, and a 31%reduction in aggregate charges and costs.We believe that we have only begun tounderstand what is needed and the extentof what can be accomplished.

AcknowledgmentsThe Truman Medical; Centers (TMC)high-utilization team model described inthis article reflects our experience andbuilds on consultative guidance providedby the Camden Coalition of HealthcareProviders. Funding is provided througha Centers for Medicare and Medicaid(CMS) Health Care Innovation Award.Project management and the primarytechnical assistance are through the

Rutgers Center for State Health Policy.The four clinical site partners of thisLearning Network include TMC, a non-profit health system consisting of 2 acute-care hospitals, serving more than 100,000patients with primary care and specialtypractices, including extensive behavioralhealth services; Neighborhood HealthCenters of the Lehigh Valley of Allentown,PA, a non-profit organization operatingtwo Federally Qualified Health Center(FQHC) look-alikes; Metro CommunityProvider Network, Aurora, CO, an FQHC;and MultiCultural Primary Care MedicalGroup, San Diego, CA, an IPA with 300physicians including .120 primary carephysicians and .14,000 members. Theauthors would also like to acknowledge thelate William E. Lafferty, MD, Merl andMuriel HicklinMissouri Endowed Chair inMedicine at the University of Missouri-Kansas City School of Medicine, for hiscontribution in designing the methodol-ogy used to evaluate Truman MedicalCenter’s care coordination interventions.

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Shauna R. Roberts, MD, is the Medical Director ofQuality for Truman Medical Centers, Kansas City,Missouri and an Associate Professor at the UniversityofMissouri-Kansas City School ofMedicine.Her focusis on measuring patient care impact through orga-nizational system development and change efforts.

Jane Crigler, MSW, is Senior Health Planner in theQuality Resources Department, Truman MedicalCenters, Kansas City, Missouri. She assists in thedevelopment, planning, implementation and evalu-ation of health services and initiatives.

Cristina Ramirez, LCSW, is a Team Leader with thecare coordination programs for chronically ill patientsat Truman Medical Centers, Kansas City, Missouri.She has a passion for partnering with patient andmultidisciplinary professionals to address social bar-riers with a strength-based focus.

Deborah Sisco, MSED, is the Guided Chronic CareProgram Manager. She leads Truman’s care



coordination team in the development, planning andimplementation of programming aimed at reducingthe high utilization rates of inpatient and emergencyservices by patients with chronic illness and assistingthem into primary care, medical homes to improvecontinuity of care and lower cost.

Gerald L. Early, MD, MA is a Thoracic Surgeon andIntensivist. He is chairman of the Clinical QualityCommittee and is the Medical Director of PatientSafety at Truman Medical Centers, Kansas City,Missouri and Associate Professor of Surgery at theUniversity of Missouri-Kansas City School ofMedicine.

As regards the Centers for Medicare and MedicaidServices, Department of Health and Human Servicessupport: The project described was supported byFunding Opportunity Number CMS-1C1-12-0001from Centers for Medicare and Medicaid Services,Center for Medicare and Medicaid Innovation. Thecontents of the article are solely the responsibility of theauthors and do not necessarily represent the officialviews of HHS or any of its agencies.

For more information on this article, contact ShaunaR. Roberts at [email protected].

The authors declare no conflict of interest.

Journal for Healthcare Quality is pleased tooffer the opportunity to earn continuingeducation (CE) credit to those who readthis article and take the online posttest atwww.nahq.org/journal/ce. This continu-ing education offering, JHQ 255, will pro-vide 1 contact hour to those who complete itappropriately.

Core CPHQ Examination ContentAreaIV. Performance Measurement andImprovements

Learning ObjectivesAfter reading this article, the reader will beable to:

• Describe an intensive care coordinationintervention that empowers high-cost,high-utilizing, medically and socially

complex, chronically ill patients to self-manage their medical conditions whileachieving the triple aim of better health,better care, and lower costs;

• Identify similarities and differencesbetween this approach and care transi-tion models which have proven effectivein reducing rehospitalizations amongpatients whose life situations do notpresent the challenges faced by thepopulation served by the program dis-cussed in this article; and

• Explain the principles undergirding thework of the care coordination team.

Posttest Questions1. Community-basedmembers of the care

coordination team:a. Establish relationships through face-to-face interactions and assist in ad-dressing patients’ social barriers.

b. May go into the home to meet withpatients but primarily use the tele-phone to check in with patientsafter they are discharged from thehospital.

c. Focus on a discrete set of topicsrelated to assuring patients under-stand the clinical directives theywere given, such as what medi-cations to take when.

d.Follow a model when patients aretransitioning from one care site toanother or to home, where fidelity tothe activities required by themodel isparamount.

2. Care coordination team activities areled by:a. A registered nurse whose focus is

clinical.b. A registered nurse whose focus is

clinical–medical and a co-equal mas-ter’s level social worker whose focus ison patients’ clinical–social issues.

c. A primary care physician and a phar-macist who focus on critical aspects ofmedication management.

d. A registered nurse whose focus is onmedical issues and a psychologistwhose focus is on patients’ behavioralhealth issues.

3. Intensive, individualized care coordi-nation as described in the article is bestused with:



a. Any population of very sick, high-cost, chronically ill patients.

b. Any patient discharged from thehospital who has low health literacyand may not understand self-carerecommendations for what they areto do when they get home, and haveno one to explain these to them.

c. A small group of high-cost “super-utilizers”who are bothmedically andsocially complex.

d. Any group of low income, inner citypatients with chronic conditionssocial complexity.

4. An individualized Care Plan used toassess each patient’s readiness to“graduate” from the care coordinationintervention contains criteria in thesedomains:a. Lists milestones the patient needs to

meet to self manage in these do-mains: Health (e.g., keeps appoint-ments, brings questions for thedoctor, knows names of meds andreasons taking them), Social (e.g.,knows how to use transportation toget to/from appointments, demon-strates skills to maintain adequatehousing), Behavioral/SubstanceAbuse(has resources/referrals to appropriateprograms).

b. Has completed the intensive hospitalreadiness for discharge throughcounseling in Medication Self-Management; has had the supportof a Dynamic Patient-CenteredRecord; and has been givenFollow-up and Red Flags for whento call the clink.

c. “Increases in Healthy Days” as re-ported by a patient at 30 and 60 days,as recordedon their tracking log thattheir hospital discharge registerednurse reviewed with them.

d. Patient self-reporting on satisfac-tion with the program and feelingshe/he has received all the infor-mation they need and is ready tograduate.

5. We have established that patients withcombinedmedical and social complexitycan and in most cases do learn anddemonstrate self-management of theirconditions. Which of the following arethe principles underpinning the carecoordination intervention:

a. It uses the strengths eachpatient bringswhen goal setting and tracking prog-ress; it believes trust relationshipsbetween team members and patientsare essential to empower patients toself-manage; it acknowledges any stepa patient takes to self manage asimportant, given competing prioritiesthat require the patients’ attention; itchallengeseverymemberof the teamtobe highly adaptable and able to stepoutside the roles/responsibilities nor-mally required of their discipline.

b.It believes it ismost effective to identifyand address deficits (such as “can’tafford copays” or “lacks transportationto get to appointments”) that impedea patient’s progress toward reachingself-management goals.

c. It thinks there is value in offeringtime-limited services introducedat hospital discharge, as patientsshould be able to “stand on their owntwo feet” if given some basic tools.

d. It is not sure that patients with cha-otic life circumstances (e.g., addic-tion) can ever really self-managetheir conditions; so it uses a short listof interventions and looks for ways tohand off patients to others in thecommunity who can continue towork with them.

6. The primary reasons for the carecoordination program are:a. To save money for the health systemand for payers.

b. To lessen the “cognitive overload”many physicians face in servinga high-utilizing patient population.

c. To train chronic disease patients inboth self-management and how touse the health system more wisely.

d. To treat all patients alike in a PatientCentered Medical Home ambula-tory setting.

7. Utilization outcomes are considereda success if:a. Outpatient visits go down, as do

emergency department visits andhospitalizations.

b. Outpatient visits stay the same, asemergency department visits andhospitalizations decrease.

c. Outpatient visits go up, as emer-gency department visits and hospi-talizations decrease.



d. It doesn’tmatter what outpatient visitsdo as long as emergency departmentvisits and hospitalizations decrease.

8. Assuring that patients are taking the“right medication at the right time” isregularly recognized as a major chal-lenge for care management programs,but for ours:a. “Taking medications as prescribed”

is, along with “building trust” amongour greatest impact steps, and wehave found that it takes time toaccomplish both of these.

b. We have tried many things toaccomplish issues of access, cost,etc., to achieve medication adher-ence and believe we have exhaustedthe things we can try.

c. We believe medication reconciliationat the time of hospital discharge andsoon thereafter should be sufficient ifcoupled with patient education andteach back to make sure patients/caregivers know what they are to do.

d. We think patient compliance is reallyup to the patient and family in theend, and we can’t really help.

9. Many patients do not need care coor-dination, but the level of intensive care

management this program offers hasconsistently produced improved out-comes for those who:a. Have one chronic illness.b. Have a working relationship with

a Primary provider that allows themto avoid visits to the EmergencyDepartment.

c. Have both medical and behavioralhealth diagnoses (and may havea history of psychologically or physi-cal trauma).

d. Have a history of successful self-management, but need a littleextra help at the time.

10. Carefully applied, the intervention isscalable and yields significant savings inthe following settings:a. It is replicable for most high-cost

patientsb. It is replicable for chronic illnesses

whether or not disease managementprinciples have been established.

c. It works in the space between the en-counters, leveraging the existing caregivers and natural support that exist orpotentially exist for the patient.

d. Is easily applied with little expendi-ture of resources.



working with socially and medically complex patients: when ...are circular, overlapping, and...

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