viernes, 22 de julio de 2016

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations | AHRQ Health Care Innovations Exchange

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations | AHRQ Health Care Innovations Exchange

AHRQ Innovations Exchange: Innovations and Tools to Improve Quality and Reduce Disparities

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations



The San Francisco Health Network embeds multidisciplinary teams within primary care practices to provide “wraparound” services to medically and psychosocially complex patients. Made up of nurses, health coaches, and social workers (and working with clinical backup from a physician), the teams provide ongoing, tailored care management and care coordination, self-management coaching, and other support, including connections to needed social services and other community-based programs. The program has significantly reduced hospital days, emergency department visits, and costs; increased patient engagement and self-management skills; and generated high levels of provider satisfaction. 

Evidence Rating(What is this?)

Moderate: The evidence primarily consists of pre- and post-implementation comparisons of inpatient admissions and emergency department visits for program enrollees, along with estimates of the associated cost savings generated. Additional evidence includes post-implementation feedback from enrollees and from providers in clinics where the teams operate. 

Date First Implemented

The first team began working in February 2012 in an adult internal medicine clinic located on the campus of the county hospital. Three additional teams began working in 2013, and a fifth team began in 2014. These teams included a second team working at the adult internal medicine clinic and one team each working at a family medicine clinic (also located at the county hospital) and a community-based primary care clinic. Due to turnover, the fifth team currently has vacancies and is being reformed with the hiring of new team members; once hiring has been completed, it will begin working out of a different community-based clinic, likely in late 2016.

Problem Addressed

Medically and psychosocially complex patients typically need care and support that goes beyond what most primary care providers (PCPs) can offer. Without needed support, they often are unable to effectively manage their own physical and mental health. Such patients frequently end up facing acute episodes that require emergency department (ED) or inpatient medical and psychiatric care.   
  • Complex needs that go beyond primary care capabilities: Patients with complex medical or psychosocial issues frequently require help with self-management, care coordination, behavioral health issues, and social service needs that go well beyond what a typical primary care clinic can offer. 
  • Frequent ED visits and hospitalizations:  Without required support, medically and psychosocially complex patients frequently end up needing ED or inpatient care, including both medical and behavioral health services. A San Francisco Health Network (SFHN) analysis found that approximately 1 percent of patients, representing those with complex needs, accounted for nearly half of all inpatient days. 

Description of the Innovative Activity

SFHN embeds multidisciplinary teams within primary care practices to provide “wraparound” services to medically and psychosocially complex patients. Made up of nurses, health coaches, and social workers (and working with backup from a physician), the teams provide ongoing, tailored care management and care coordination, self-management coaching, and other support designed to enhance health and functional status. Known as the Complex Care Management Program, this initiative consists of the following key components: 
  • Identification of eligible patients: The program is available to patients who have been admitted to the hospital three or more times in the past year and to other high-risk patients who are referred by their PCPs or inpatient providers. Through various electronic medical record (EMR) systems, the program coordinator regularly retrieves a list of those meeting the hospitalization criteria and then contacts each patient’s PCP (usually by e-mail) to verify the patient's appropriateness for the program. PCPs and inpatient providers also proactively contact the coordinator, either in person during clinic huddles or by e-mail, to refer patients at high risk of a future hospitalization, including those currently or recently hospitalized. When contacted about a referral, the coordinator verifies the reasons for referral and clarifies program-related goals for the patient. Before determining final eligibility, the coordinator uses a feature in the EMR system to screen out individuals already served by other SFHN programs that offer similar services, such as the ED Case Management program and the Homeless Outreach Team. 
  • Initial contact and program enrollment: The program coordinator contacts eligible individuals to explain how the program works and its benefits. Whenever possible, such contact occurs in person, either in the clinic or in the hospital. If that is not possible, the program coordinator attempts to contact the individual by phone for a period of up to 3 months. To date, approximately 52 percent of eligible individuals have chosen to enroll. Most are middle aged and have multiple (four to seven) chronic diseases, and many also have serious mental health or substance abuse problems. As of April 2016, approximately 175 patients were actively enrolled in the program, and the program has served a total of 254 patients. 
  • Nurse with patient. Image courtesy of Iveht Pineda. Used with permission.
    Nurse with patient. Image courtesy of Iveht Pineda. Used with permission.
    Inperson introductory meeting to build trust, assess patient: 
    The team nurse and health coach conduct an approximately hour-long comprehensive assessment, typically in the home but sometimes in the clinic (e.g., if the patient is homeless or for some other reason prefers the clinic location). The assessment always begins with the team members asking about the patient about his or her concerns, perceived strengths and needs, and personal goals. The primary purpose is to build trust so the patient will later react positively to the team’s coaching, education, and self-management support. The remainder of the assessment involves a review of various domains, including medical issues (e.g., medications), self-management skills, functional status (including activities of daily living), mental health, substance use, cognitive skills, home and interpersonal safety, and social support. The team generally keeps this initial visit to an hour, which means that some areas may not be covered at this time. 
  • Care plan and initial assignment to level of care: After the inperson meeting, the team uses all available information to develop a detailed care plan that includes a manageable number of concrete goals for the patient. As part of this plan, the team assigns the patient to an intensity level, which defines the initial frequency and degree of ongoing monitoring and support. Those who are currently hospitalized or have recently been discharged from the hospital typically begin with a “critical” designation, which calls for multiple visits or calls each week. Most others start at level 1, which calls for weekly contact. As discussed in more detail below, the levels are dynamic (ranging from 1 to 4), with patients changing as their conditions stabilize or worsen. 
  • Ongoing coaching, engagement, and support: Teams provide ongoing support through regular inperson visits and phone calls. Early contacts tend to focus on additional trust-building, often by securing an “early win” for enrollees, such as obtaining a needed piece of equipment (e.g., a wheelchair) or fixing a problem with a local pharmacy. Once trust has been built, sessions focus on coaching and education designed to help patients reach their established goals, along with making connections to needed social services and other forms of community-based support, including those that assist with mental health, substance abuse, housing, nutrition, legal, employment, and other issues. Additional details about this phase are provided below:
    • Service location and team roles: Depending on the patient’s needs and preferences, services may be delivered in person (typically in the clinic, but sometimes at home) or by phone, with the mix often shifting over time as the patient progresses toward his or her goals. Typically, one team member handles a given visit or call, with the nurse handling patients with predominantly medical needs (e.g., medications, management of one or more unstable chronic diseases) and health coaches handling those who are more stable medically but need ongoing education and support. If necessary, a health coach can bring in the nurse to assist with clinical issues or a social worker to assist with complex behavioral health and other support issues outside the scope of the health coach. To facilitate these handoffs, the nurse and coach are co-located in the same office. 
    • Gradual reductions in intensity, graduation: The intensity and frequency of support tends to decline over time. Enrollees progress through intensity levels that follow a numerical scale based on the number of weeks between scheduled contacts (2, 3, or 4). Level 5 patients are instructed to call the team as needed, with no proactive check-ins from the team. After roughly 12 to 18 months, enrollees typically “graduate” from the program when they meet their care plan goals, an indication that they no longer need ongoing support. (The goal is for enrollees to graduate in a year, but not all do so.)
  • Weekly team meetings to discuss select patients: Each team meets weekly to discuss high-priority patients, such as those in or recently discharged from the hospital, those struggling with behavioral health issues, newly enrolled or referred patients, and those who may be ready to graduate. The medical director serves as a clinical consultant during these meetings. The nurse manager and program coordinator facilitate discussions about programmatic issues. The teams use a dashboard to identify patients who will be discussed and to review process metrics (such as enrollment) related to the overall program. Meetings generally last an hour, although the two teams who are co-located in the adult internal medicine clinic hold a combined meeting that lasts 90 minutes. Each team typically reviews between 3 and 12 patients during a meeting. 
  • Ongoing communication with clinic staff: PCPs and clinic-based staff keep abreast of routine team-related activities through the patient’s EMR, which team members update on a regular basis. As necessary, team members e-mail, page, or call the provider team about time-sensitive issues, such as the need for a medication change or specialist referral. Since they are co-located at the clinic, team members also participate in daily morning clinic huddles or otherwise reach out to the provider team in person about patient-related issues. 
  • Information technology (IT) reminders and other support: Team members use various IT systems (including embedded EMR functionality and a database built using commercially available software) to keep track of those assigned to them and to document all program-related activities (e.g., phone calls, home visits, referrals to social service programs). These IT systems automatically send reminders to team members about the need to complete important tasks, such as a referral or scheduling a phone call or home visit. 

Context of the Innovation

The health care delivery arm of the San Francisco Department of Public Health, SFHN is a comprehensive, integrated health care system that provides primary care, emergency and trauma care, behavioral health services, medical and surgical specialty care, dental care, diagnostic testing, skilled nursing and rehabilitation services, homeless health services, and health services for incarcerated people. Roughly 90,000 low-income San Franciscans who are either uninsured or covered by Medicare or Medicaid receive their primary care from SFHN. 
The impetus for this program came from the growing recognition among leaders of SFHN primary care clinics that a small percentage of their patients accounted for a disproportionate share of hospitalizations, and that many of these hospitalizations could have been prevented if patients had more ongoing support. With passage of the Affordable Care Act (ACA), SFHN found itself with a large number of newly enrolled Medicaid patients from the San Francisco Health Plan (the local Medicaid plan). In addition, the delivery system bore full financial risk for hospitalizations under its contracts with the plan. Facing a rapid increase in the number of complex patients for whom it bore full financial risk, SFHN leaders sought funding for this program through the Delivery System Redesign Program, which was part of a Section 1115 Medicaid waiver through the California Medicaid program. SFHN secured the waiver funding, which allowed the organization to implement a variety of care redesign initiatives, including the Complex Care Management Program.


The program has significantly reduced hospital days, ED visits, and costs; increased patient engagement and self-management skills; and generated high levels of provider satisfaction.
  • Fewer hospital days and ED visits: For the first 254 patients enrolled in the program, hospital days have fallen by 41 percent, while ED visits have dropped by 37 percent. These figures compare the average number of hospital days and ED visits since enrollment to the average during the year-long period before enrollment. The decline in hospital days translates into an average of 4.16 avoided inpatient days annually for each enrollee.  
  • Significantly lower costs: At the program’s current capacity of 225 enrollees and based on a fiscal year 2013-2014 analysis that estimated the average cost of an inpatient day at San Francisco General Hospital to be $5,156, the aforementioned reduction in hospital days would generate estimated annual savings of just under $5 million, significantly more than the estimated $1.4 million in annual program operating costs needed to serve this number of patients. The aforementioned decline in ED visits would generate additional cost savings, making the program more cost-effective.
  • More engaged patients, with better self-management skills: In qualitative interviews with 13 patients, program participants reported feeling more motivated to engage in healthier behaviors and more in control of their health as a result of their participation. Beginning in January 2016, health coaches began collecting more systematic qualitative feedback from enrollees about the program’s impact on their level of activation and engagement and their willingness to refer a family member or friend to the program. Results should be available later in 2016.
  • Highly satisfied providers: Provider surveys show high levels of satisfaction with the program across multiple domains, including communication with patients and family members, coordination of care, monitoring of chronic conditions, referrals to community resources, and efficiency of office visits.

Evidence Rating(What is this?)

Moderate: The evidence primarily consists of pre- and post-implementation comparisons of inpatient admissions and emergency department visits for program enrollees, along with estimates of the associated cost savings generated. Additional evidence includes post-implementation feedback from enrollees and from providers in clinics where the teams operate. 

Planning and Development Process

Key steps included the following:
  • Hiring and training team members: Hiring and training has occurred on an as-needed basis, driven by turnover and program expansion. In all hiring, program leaders look for nurses and coaches who have a proven record of working effectively in a primary care clinic; experience in other aspects of the job (e.g., care coordination, care management, coaching, motivational interviewing) is preferred but not required. SFHN provides training on relevant EMR systems and program-related forms, motivational interviewing, trauma-informed care, and coaching. Health coaches also receive training on self-management coaching for diabetes, congestive heart failure, hypertension, and chronic obstructive lung disease. Before working on their own, new hires spend substantial time with experienced team members, first shadowing them and later being observed by and getting critical feedback from them. The program’s medical director and nurse manager regularly check in with team members to see if they need extra support.   
  • Initial implementation in one clinic and subsequent expansion: After hiring and training the first team, SFHN implemented the program in one hospital-based adult internal medicine clinic in 2012. This clinic serves a significant number of complex patients who had high rates of hospitalization. Program leaders expanded the program to four teams in 2013, and added a fifth in 2014.
  • Shifting several teams to new clinics: After evaluating hospitalization data, program leaders realized in 2014 that three of the five teams were working out of clinics that did not serve a high volume of medically or psychosocially complex patients. An analysis showed that 6 of SFHN’s 15 primary care clinics accounted for 84 percent of frequently hospitalized patients and that three diagnoses (congestive heart failure, angina, and pneumonia) accounted for 27 percent of all admissions for these patients. This information was used to shift three of the teams to clinics that serve a higher volume of complex patients.  
  • Participating in learning collaborative: In 2014, SFHN leaders joined the Institute for Healthcare Improvement (IHI) Better Health and Lower Costs for Patients with Complex Needs Collaborative. Participation in the collaborative helped those involved in the Complex Care Management Program understand the importance of getting to know the target population, through both quantitative analysis and qualitative interviews with patients and providers. The collaborative also emphasized the importance of using small, rapid tests of change and then making adjustments and refinements based on the results. Program leaders and staff have also benefitted by learning from the other programs that participated in the collaborative. 
  • Ongoing refinements: Using their experiences from the IHI collaborative, program leaders regularly evaluate how the program is operating (including getting feedback from the teams, other providers, and enrollees), and work with the teams to make improvements as necessary.  

Resources Used and Skills Needed

  • Staffing: The program currently has four full-time nurses, four full-time health coaches, one full-time social worker (who works in the community-based clinic), two part-time social workers (who each spend roughly 10 percent of their time supporting the hospital-based clinic teams), and a part-time program coordinator (80 percent), director (30 percent), and medical director (15 percent). Program leaders are currently hiring a nurse and health coach to fill vacancies on the fifth team, along with a part-time nurse manager to oversee all the teams. (At present, the director spends some of her time overseeing the teams.) Each nurse–coach team can handle up to 50 enrolled patients at a time; the team with the full-time social worker can handle an additional 25 patients, bringing the total current program capacity to 225 patients (275 once the fifth team is back in place).  
  • Costs: Once the fifth team and nurse manager are in place, total program costs will be roughly $1.8 million a year. At full capacity (275), the annual cost per enrolled individual will be approximately $6,380. 

Funding Sources

The Centers for Medicare & Medicaid Services provided 5 years of funding as part of the previously described Medicaid waiver program; these funds supported hiring of the nurses, health coaches, and social workers. The program is now fully supported by the San Francisco Department of Public Health.

Getting Started with This Innovation

  • Get to know target population: A first step is to conduct both qualitative and quantitative analyses of the target population, including interviews with patients and their providers to get a sense of their respective strengths and needs. As noted, SFHN program leaders use this type of information to make ongoing program adjustments.  
  • Develop staffing mix based on patient needs: The needs of the target population should drive decisions on staffing mix. For example, patient populations with a high prevalence of unstable chronic disease will need a more nurse-intensive model. By contrast, those with high rates of psychosocial vulnerabilities will need more health coaches, and those with high rates of mental illness or substance abuse issues should rely more on social workers.
  • Emphasize importance of building trust with patients:  Patients who trust the team members are much more willing to take control of their health and make positive changes. As a result, hiring and training processes should emphasize and reinforce trust-building skills, including the need for empathy and compassion.   
  • Create tracking structures: Teams need electronic and other structures (including reminder systems) to keep track of their patients’ needs. Early on, SFHN built a database using commercially available software for this purpose. Recently, the program began transitioning to using the EMR for its reminder systems. 
  • Co-locate team members if possible: Having the nurse and health coach work out of the same office can be quite helpful, as it allows each to “hand off” a patient to the other when appropriate during phone-based interactions.

Sustaining This Innovation

  • Consider hiring a separate outreach coordinator: As the program grows, team members may become so busy with current enrollees that they do not have time to reach out to potential new ones. If this occurs, programs should consider creating a separate outreach position on either a full- or part-time basis. 
  • Create structure in daily routine: Those served by this program often have a lot of crisis and chaos in their daily lives, and hence it is no surprise that the team’s work can get very chaotic as well. While team members need to react to short-term crises as appropriate, they also need some degree of formal structure to their day to make sure that routine, nonurgent tasks can get done. To that end, program leaders have begun testing various strategies for creating more structure, including use of quick, scripted morning huddles where team members briefly review their daily schedule; 15-minute daily meetings where nurse–coach dyads conduct case reviews (rather than doing so on an ad hoc basis throughout the day); and establishing formal blocks of time during the day dedicated to certain activities (e.g., making phone calls/home visits in the morning, responding to e-mails and EMR messages from other clinicians in the afternoon), with formal process goals for each time period (e.g., six phone calls during a 2-hour block). 
  • Keep everyone working at top of license: To maintain morale and cost-effectiveness, it is important to regularly remind the teams that nurses, coaches, and social workers should each be operating at the top of their licenses (i.e., practicing to the full extent of their education and training, not spending time on tasks that someone else could perform effectively) and should adhere as much as possible to their discreet team roles.  
  • Celebrate successes: Team members have very stressful, chaotic jobs that regularly involve disappointments. Consequently, program leaders need to consciously think about morale issues and make a point of publicly celebrating successes on a regular basis, including at the program, team, and individual enrollee level.  
  • Integrate teams into clinics as much as possible: To the extent possible, team members should be physically located near clinic staff and otherwise integrated into clinic operations. Such integration facilitates communication between the teams, PCPs, and other clinic-based staff. 

Contact the Innovator

Elizabeth Davis, MD
Medical Director of Care Coordination
San Francisco Health Network Primary Care
Assistant Clinical Professor
Division of General Internal Medicine 
University of California, San Francisco
(415) 206-4940
Anna Robert, RN, MSN, DrPH
Director of Care Coordination 
San Francisco Health Network Primary Care
(415) 759-3596
Gurleen Kaur 
Program Coordinator and Data Analyst
Complex Care Management Program
San Francisco Health Network Primary Care
(415) 206-5278

Innovator Disclosures

In addition to the organizations listed in the Funding Sources section, Dr. Davis, Ms. Robert, and Ms. Kaur reported that SFHN has received financial support for activities directly and indirectly related to the work described in this profile, as described below:  
  • Grant funding from the National Institute on Minority Health and Health Disparities and the Bechtel Foundation (through the University of California at San Francisco Program for the Aging Century) to support program evaluation
  • Travel and tuition support from the California Health Care Foundation and the Center for Care Innovations to support participation in the IHI collaborative 
  • Payments from the Pacific Business Group on Health to support Dr. Davis’ leadership of a workshop on care coordination as part of California’s Health Homes program
In addition, Dr. Davis reported receiving support from the Kaiser Permanente Community Benefit Fund to cover travel expenses for an IHI national meeting in 2016.   

References/Related Articles

Mitchell K. How to improve the health of patients with complex care needs. Improvement Blog. Institute for Healthcare Improvement. June 22, 2015. Available at: is external)
Davis E. An interdisciplinary approach to improving care, decreasing hospital stays. America’s Essential Hospitals. November 24, 2013. Available at: is external)
San Francisco General Hospital Foundation. Managing complex care for San Francisco’s most vulnerable. Foundation News. Winter/Spring 2014. Available at: 

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