Lessons from the Field

diane-craig-mdKaiser Permanente Santa Clara Medical Center is a general medical and surgical hospital in Santa Clara, CA. The following is a description of the lessons learned from a team at Kaiser Permanente, Santa Clara, who spoke with their providers about the needs their patients have and the challenges they face in providing care. The goal was to gain deeper insight into root causes of high utilization and the interventions likely needed in their enhanced care model. Challenges patients face in their lives and barriers in the healthcare system are prominent themes.

What needs do patients have that our programs are not set up to manage?

  • Healthy nutrition program
  • More timely mental health support: Mental health issues need to be addressed as aggressively as medical conditions
  • Language barriers
  • More social workers to assist with managing these patients
  • Community support (financial and home care)
  • Transportation to and from medical appointments

What are the biggest challenges you face in fostering good patient outcomes?

  • Non-adherence to treatment plan
  • Getting patients to take charge of their life
  • Patient and physician have conflicting health care goals
  • Cost of medication, treatment, and co-pays
  • Not enough time during medical appointment
  • Providers working in silos, treatment plans lack broader view
  • Not clear on what programs offer what things, especially in outpatient setting: Would love to be able to have stronger social services support for outpatients.
  • Psychiatric diagnosis or cognitive impairment that interferes with ability to follow through on care plans 
 Diane E. Craig, M.D., F.A.C.P, Assistant Physician-in-Chief, The Permanente Medical Group, Santa Clara Medical Center


Visiting Nurse Service of New York and VNSNY Hospice and Palliative Care is a not-for-profit home- and community-based healthcare and hospice organization in the greater New York metropolitan area and The Allure Group, a network of skilled nursing facilities and rehabilitation centers in NYC. The following is a description of the lessons learned from VNSNY and their partner from their interviews with individuals, caregivers, and providers about their chosen population segment: Nursing Home residents eligible for hospice care.

“As our two organizations worked in partnership to transform end of life services in nursing facilities we identified the following as it relates to advanced care planning options:


  • Lack of knowledge about what hospice provides and criteria for admission
  • Myths and stereotypical attitudes about hospice
  • When hospice care is appropriate
    • Where hospice care is delivered
    • How hospice care is paid for
  • Health care practitioner and physician barriers to patients gaining access to hospice care, and varying degrees of use
  • Conflicts between individual’s spiritual and cultural beliefs and the goals of hospice care
  • Low health literacy among patients and lack of understanding about hospice care”Adina Kolatch, Consultant, Visiting Nurse Service of New York

clemens-hong-pictureThe following information is from Clemens Hong, MD, who shares his experience and lessons learned on conducting stakeholder analyses.

“In order to run a successful program, you need to start by selecting a population for which you have a set of interventions that will achieve outcomes that are important to you in the time frame you want to achieve those outcomes. That’s a one line summary. I think about in terms of program design. If you want to do your set of interventions, you need to think about the whole pathway when you select your patients.

Many programs will start with their data to select their high-risk, high-utilizers. Then the question that they don’t ask is, “Do those populations matter to the leadership who you want to fund your program sustainably going forward?” For a population for which you can’t hope to achieve a return on investment within the first five years, leaders might say, “It’s a great program, but where’s the money?” You really need to do that stakeholder engagement ahead of time. Then you need to work backward from that to some extent. You could have the perfect risk prediction algorithm for identifying people who are high risk with mental illness, and you could have no mental health delivery system to care for them. You can perfectly select people for the wrong set of interventions. You have to think through the intervention piece. Critical starting points include: stakeholder engagement, asset mapping, knowing what’s important to the people that are going to pay for the program, support at an executive leadership level, what’s important to our patients, who are the patients we have in our system and how can we can better understand them. Once you have that, you can select a segment of patients in alignment with your stakeholders. For example, once you’ve done an analysis to determine that: your leadership wants a three-year return on investment rather than a six-month return on investment; or they are really interested in the experience of the patients; or they want you to work with the ED and primary care; or  you have a strong ED, primary care system and addiction services infrastructure, but not a good mental infrastructure — only then you can say, “OK, who are the patients and how are we going to select them to achieve a three-year return on investment working with an ED high-utilizer population, with a set of interventions that focus on addiction, and leverage good ED doctors, primary care, and teams?” Once you have a shared vision of the program, the goals, and the care model, it is more likely to gain ongoing support.”Clemens Hong, MD, a primary care physician, and Medical Director of Community Health and Improvement for Los Angeles County, California