Online Program

Primary care for complex patients in a self-insured worksite health plan

Wednesday, November 6, 2013 : 11:30 a.m. - 11:45 a.m.

Ann Lindsay, MD, Co-Director, Stanford Coordinated Care, Stanford School of Medicine, Palo Alto, CA
Stanford Coordinated Care, established April 2012, is an offering through the self-funded health plans of Stanford University, Stanford Hospital and Clinics and Lucille Packard Children's Hospital. SCC recruits patients projected to be amongst the top 10% spenders of the 36,000 employees and adult dependents for Primary Care Plus and from 10-20% for Chronic Care Support. Both programs provide relationship-based care focusing on the patient's own goals of care and promoting self-management. Chronic Care Support patients meet in-person with an RN or Social Worker but receive primary care elsewhere. Primary Care Plus and Chronic Care Support services were designed based on interviews with employees with chronic conditions and analysis of claims information. SCC is capitated; there is no co-pay for services at SCC. The Primary Care Plus team includes a Licensed Clinical Social Worker, a Physical Therapist specializing in treatment of chronic pain, a Clinical Pharmacist, a Clinic Manager with a background in LEAN quality improvement and Care Coordinators. Care Coordinators are Medical Assistants with additional training at SCC who function in an expanded role and pay scale. They have their own panel of patients, scribe visits, assist with patient-generated assessments, refill medications and order routine lab and Xray based on protocols. Care Coordinators maintain regular contact with patients between visits by secure e-mail or telephone. There are three Care Coordinators per Clinician. SCC has developed a registry that extracts data from claims and EPIC EHR, incorporating metrics and care gaps for 10 chronic conditions to help the team focus on patients at highest risk and ensure completion of evidence-based routine care. A patient view, named Health Portrait by our patient advisors, demonstrates risk factors amenable to change and graphs progress over time. We seek to achieve the Triple Aim: patient satisfaction, improved clinical outcomes, and lower cost. Our fourth aim is staff satisfaction. We project 1,300 patients during our third year of operation, when a formal research study with be conducted using Propensity Score Matching and Coarsened Exact Matching. SCC was hailed as a model practice by a JACHO team formulating Medical Home standards. We are interested in propagating the SCC model because of its potential to reduce costs without reduction of quality or access.

Learning Areas:

Chronic disease management and prevention
Provision of health care to the public

Learning Objectives:
Describe a work-site capitated clinic for patients with complex conditions designed to increase patient satisfaction, improve clinical outcomes and reduce cost Identify practices to implement team care, support high risk patients, and provide relationship-based care

Keyword(s): Chronic Illness, Cost-Effectiveness

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am Co-Director of Stanford Coordinated Care and Clinical Professor at Stanford School of Medicine. I worked with a team to develop the model of care and work in the clinic described in the presentation. Our clinic focuses on care of employees and their dependents with complex chronic conditions to achieve the triple aim of improved outcomes, greater patient satisfaction and controlling costs.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.