Stanford Coordinated Care (SCC) is a primary care clinic for Stanford employees and dependents on the self-insured health plan who are at high risk for poor (and expensive) outcomes. SCC was established under the stewardship of Arnie Milstein, MD, from the Stanford Clinical Excellence Research Center. The co-directors designed a fully capitated care model based on extensive interviews with 34 Stanford employees with chronic health conditions, in which they shared what worked for them and what they found challenging in achieving the best health possible. The interviewees identified coordination of services as their primary challenge and many reported feeling that providers did not adequately listen to them to address issues of importance. Many of the interviewees continue to serve as patient advisors to SCC.
Analysis of insurance claims showed that pain, depression, poly-pharmacy, and medical complexity were common among the SCC target population; services were designed with these needs in mind. To maintain a reasonable workload given the complexity of the target population's health care needs, physician panels are limited to 300 patients, and medical assistant care coordinators are limited to 100 patients per panel.
The SCC model of care
Every morning the SCC team huddles to review the day's schedule for potential snags, plan for procedures, and review timing of slots reserved for acute visits. Acute visits are 15-30 minutes and are handled together by the care coordinator and physician. After-hours calls from patients are handled by the patient's primary care physician (PCP), who knows the patient and his or her health issues.
The initial SCC visit for new patients takes a total of two hours. Before the visit, the primary care physician will have reviewed the patient's records, updated the problem list and past history, and huddled with the care coordinator about the new patient.
The care coordinator who will manage that patient's care greets the patient at the front desk, escorts the patient to the exam room, and begins a half-hour process of onboarding the patient to SCC, discussing important information (e.g., how the clinic functions, services offered, patient expectations, and how to receive acute care and after-hours advice) and populating the medication list. The care coordinator will also perform intake assessments including:
Patient Activation Measure (PAM)
Depression screen (PHQ-2 and PHQ-9)
Physical and mental function (Short-Form 12® or VR-12)
The care coordinator then huddles briefly with the physician, who then joins the visit for the next hour, where the focus is on establishing a trusting relationship, having the patient tell their “story,” defining what matters most to them, and setting their goals for the upcoming year. The physician uses open-ended questions to understand the specific challenges facing the patient within four challenge domains:
Experience with health care
Self-management and mental health
The care coordinator remains in the room to document the visit, complete orders, and arrange follow-up care during this discussion. The care coordinator actively joins in the conversation between the physician and patient during the visit. The patient sees the care coordinator as an important team member, which has several benefits:
The care coordinator is trusted and knows the patient's story.
The potential for errors that occur during hand-offs to other team members is minimized.
The care coordinator becomes educated on the nature of the chronic conditions the patient is facing, including the subjective complaints, objective findings, and important patient education that they can provide.
Focusing on what matters most to the patient and the patient's overall goals for the upcoming year rapidly builds trust with patients. For one patient, the goal might be to lose weight or control their diabetes. Another may want to attend a family reunion away from home, which requires that they improve their mobility. The patient and care team establish one or more action plans, which are documented in the problem list under the patient's goals of care. The patient's “shared care plan” is elicited via motivational interviewing and consists of discrete achievable actions the patient feels confident he or she can complete successfully in the short term. The provider's action plan may involve attending a specialty visit with the patient, soliciting educational materials or support group information from the health librarian, or further delving into the patient's medical history.
The provider then exits to document the assessment and care plan and the care coordinator completes the visit. The care coordinator conducts wrap-up activities, including:
Drawing necessary labs.
Confirming the patient's understanding of the visit.
Review the action plan(s).
Agreeing on a follow-up plan to check in about how the action plan went for the patient over the coming week.
Arranging referrals both within and outside the SCC.
Sending prescriptions to the patient's preferred pharmacy.
For primary care planned-care visits, the established patient has an hour scheduled with his/her care coordinator and primary care physician following a format similar to that used for the intake visit. A pre-visit huddle is done electronically or in person. During the first 15 minutes, the care coordinator:
Carries out routine tests by protocol.
Asks the patient, “What bothers you the most?”
The physician joins for 30 minutes for a clinical and social update, physical exam, and action planning. The care coordinator then takes 15 minutes to check the patient's understanding, review the action plan, and confirm follow-up instructions.
Care is focused first and foremost on addressing patients' self-identified goals, often requiring patience on the team's part to not focus on the glaring non-emergent health problems that surfaced prior to and during the visit. A discrete action plan is finalized with the patient, using motivational interviewing when indicated to define both the importance of the plan and the patient's confidence in carrying out the plan to ensure that it will be successful. As trust is established over a visit or two, the team becomes more successful in addressing not just the patient's concerns, but the concerns of the medical system, as well. For example, a patient with an A1C of 16 who was only interested in his palpitations may ask after the second or third visit, “Shouldn't I do something about my diabetes?”
The team built for success
Weekly clinical and operations meetings are held for all team members. Care coordinators present all new patients to the group, which improves their communication skills and ability to determine what issues are important. The team then decides who should become involved in each patient's care going forward, for example:
A physical therapist.
A behavioral health specialist to address depression or anxiety.
A dietitian for weight loss or special diet planning.
A pharmacist to conduct medication review and education.
A diabetes educator to address diabetes, hypertension, lipids, or asthma.
A nurse accompaniment to a specialty consult.
The licensed clinical social worker (LCSW), physical therapist, pharmacist, and dietitian see patients on their own schedules, and only rarely is the care coordinator or PCP in attendance. The clinical nurse specialist supervises the care coordinators and meets with hospitalized patients for care transition planning, following up with a phone call (if low risk) or home visit (if the admission was emergent or the patient is considered to be at high risk for readmission).
The SCC team works in a shared workspace, which promotes moment-to-moment, in-person collaboration. All team members are encouraged to address operational issues; as SCC utilizes Lean as a quality-improvement method, team members at every position have crafted A3 problem analyses and improvement plans. As a result, SCC is continually improving, and staff satisfaction measures 100 percent.
Use this template to create your own A3 one-page report.
How the model works
As SCC is capitated for services it provides and paid by the month rather than by the visit, alternatives to in-person visits are encouraged, which protects the time needed for the longer-visit model described above.
The care coordinator enrolls every willing patient in a secure e-mail system on the patient portal at the intake visit. The next day, she sends a message to see who fails to respond, learning who requires more IT help. As a result of this protocol, 95 percent of SCC patients regularly communicate with the team by e-mail. Fifty percent of the e-mails are handled by care coordinators, with physicians handling messages requiring medical judgment.
The SCC sends all lab and X-ray results, primary care visit notes, and specialty consults to their patients via the secure patient portal. SCC also offers phone and video visits for patient convenience. The care coordinators check in with patients on an average of one two-way contact a week to:
Check on the patient's action plans.
Assist with scheduling.
Help with refilling routine medications by protocol.
Ensure completion of preventive care or disease-specific monitoring (e.g., routine mammograms, immunizations, or colon cancer screening) by protocol.
You can find the SCC care coordinators' protocols on the Stanford website.
Commitment to quality
SCC has two dashboards that draw from the electronic medical record (EMR):
The care gaps dashboard alerts care coordinators about routine tests and immunizations that are due.
The risk dashboard identifies patients who are high risk for poor and/or costly outcomes.
Care gaps are the responsibility of the care coordinators working under protocol. The SCC care coordinators have achieved the 90th percentile on 9 of 10 Healthcare Effectiveness Data and Information Set (HEDIS) measures. The whole team meets monthly to review which patients are at elevated risk and to plan care for those patients proactively, rather than waiting for the patient to appear in the ED.
The SCC patients appreciate the services provided to them, and the SCC team members enjoy their work. The SCC has scored in the 99th percentile in the Press Ganey® “Likelihood to Recommend” category for 19 of its first 20 months.
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