Developing a Care Model


“Begin your efforts by going through design thinking, which sets up the improvement team to focus on the core needs to be met, helps the team question traditional assumptions, and see the problems in a new light. It also sets up a culture of learning so that you keep learning as you go forward. We really believe in the powers of five thinking (i.e., starting with five patients, then expanding to 25, then 125, etc.).

Each stage presents questions that are important to learn from. In working with an initial five people you begin to identify the stuff that might be important, and then you try to deliver it to five people but without the constraints of budgets and business plan and all of that. Then you begin to say, ‘This is the work and let’s see what we have to do to get to 25 people,’ and that starts to involve staff that are not volunteers experimenting. You can begin to develop standard work on the 25 to learn what we want to do reproducibly every time even though the actual intervention is individual to each patient, at least at each patient activation level.

Moving to serving 125 patients, you have to understand the panel sizes for different members of the team. So, at this stage, you have your impactful interventions, standard work for the care teams, and an understanding of caseload sizes. And then when you’re scaling up another fivefold to 625, you basically set up a situation, if you’re lucky, where the people supplying your resource agree on what is full scale and they start staffing you pre-emptively when you’re coming up against the need for new people rather than having to beg each time. There should be an agreement on the front end and a business plan. So, it’s a process of doing that well that leads to sustainability and scale in a program. If the agreement is that you have one thousand patients because that’s what the data says you need to do to really bend the cost curve in your environment, then you don’t want to have to be begging for each staff hire when you get past 125 patients. I’m not sure why we would do all this if it wasn’t about sustainability and scale.”Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care

Why is this important? And what do we know?

  • A care model is a set of interventions, activities, and tasks that is carried out consistently and targeted to a given population. It includes the array of care team members, their roles and responsibilities, the frequency of care delivery, and the protocols that they follow. The care model is designed, in total, to interact with people to improve their circumstances in predictable ways.
  • Developing the “right” care model for your populations with complex needs and high costs is important for:
    • Matching the care model (care team and services) to the needs and assets of your population
    • Achieving the best health outcomes for your population
    • Enabling care teams to find joy in their work
    • Achieving your organization’s goals around health care utilization
    • Sustaining enhanced care over time, a key consideration in the development of an enhanced care model
  • Your improvement team can use principles of human-centered design to refine or develop a care model that aligns with the needs and assets of your population. The process includes defining the goals, assets and needs from the patients’ perspective, understanding the context in which care is currently delivered, developing a shared concept for how a new care model might be delivered, pilot testing the model, and refining the enhanced care model. Stanford Coordinated Care, an ambulatory care ICU serving Stanford University employees, went through a design process to understand how to craft their interventions. Review a summary of this process and resulting enhanced care model.
  • To increase your learning, talk with patients that fit the characteristics of your chosen population segment who are and who are not successful in getting their health care needs met. Use this information to create a vision of why some people are successful in getting their health care needs met and others are not, and then brainstorm solutions that enable people to be successful. Effective care models are developed through many cycles of prototyping, testing, and learning.
  • Successful care models for populations with complex needs and high costs have several common features. These care models have established reliable processes to:
    • Assess a comprehensive set of patient health conditions, behaviors, risks, supports, resources, values, and preferences. Find resources in the Revolutionizing Patient Engagement section.
    • Deliver and monitor evidence-based care that meets the patient’s health-related needs and preferences
    • Use multidisciplinary care teams that include specially trained care managers, physicians, and other providers
    • Coordinate and communicate across all providers engaged in a patient’s care, especially during transitions in care
    • Support person-to-person encounters, including home visits
    • Coach patients and families to actively engage in self-care and to recognize problems early
    • Activate informal caregivers, such as family or friends, to support patients in the home
  • Execution of the social and technical aspects of the care model also matters. Do not reinvent the wheel. Learn from others who have been successful and become familiar with the evolving literature in this area. However, your enhanced care model will only be effective if you are successful at adapting those good ideas to your context — to your patient population, to your staff, and to your strategic purpose.
  • Use systematic, robust quality improvement methods and an iterative learning process using Plan-Do-Study-Act (PDSA) cycles to redesign the interventions, workforce, workflows, and other components of your organization’s enhanced care model. Tracking data over time using run charts will help your team learn about what changes are most effective.
  • Learn how to deliver and improve your care model by using the proactive 5x model (i.e., 5, 25, 125, 625, etc.) where improvement hinges on small, iterative changes. In this approach to human-centered design, begin by working with five patients and learn by co-creating and testing the effectiveness of individual care plans. Continue to learn by testing and building your care model with 25 new patients. Build reliable care processes as you move from 25 to 125 patients and beyond. This deliberate scaling approach enables your improvement team to identify the effective elements of your enhanced care design, while safeguarding against making a large investment that is not effective.

Core recommendations

Develop a care model that fits the needs and assets of your chosen population segment, and aligns with your context.
  • Develop a care model that meets the needs and assets of your population with complex needs and high costs, and aligns with the values, structure, and context of your organization. Begin by identifying the patient population’s needs and assets, then test service delivery to meet those needs. Organizational alignment will help your organization leverage its strengths, and find opportunities to build partnerships or develop new services. It will also help your improvement team proactively explore potential return on investment.
  • Your care model will evolve over time to reflect the team’s deeper understanding of the needs and assets of your population.
  • Detail to develop a care model that fits the needs and assets of your population with complex needs and high costs, and aligns with your context.
Prepare for care redesign by co-creating individualized care plans and learning alongside five patients.
Develop your enhanced care model through iterative testing with 25 additional patients.
  • Based on your experience with five patients, identify useful interventions and develop a plan to test those interventions as you grow your program to 25 patients. This cycle of improvement enables your care team to continue to improve the care model, core interventions, staff roles and training mechanisms, measurement systems, and workflows.
  • Begin to establish reliable work processes that can support the enhanced care model. The process of iterating upon and refining your care model is an ongoing process, and will continue as the program grows beyond working with the first 25 patients.
  • Detail to develop your enhanced care model through iterative testing with 25 additional patients.
Develop work processes to ensure consistent care delivery as the program grows from 25 to 125 patients, and beyond.

How to get started designing or refining your enhanced care model

Try these steps to get started with designing or refining your enhanced care model:

Use a structured learning process and quality improvement methods to learn how best practices and ideas that have been successful elsewhere can be adapted to your context.
Once you have determined the assets and needs of your population, identify immediate changes that you can test to improve care for this population. Examples of change ideas to test include:
  • Try a different recruitment method, such as meet the person when they are in the hospital.
  • Meet the person in their home or in another setting they are more comfortable in.
  • Test if a trained medical assistant or community health worker can do the initial engagement session.
  • Test different session openings such as asking the person “What is important to you?” or “What help do you need in the next 24 to 48 hours?” to begin to develop a person-driven care plan centered on the person’s own goals, priorities, and preferences.
Ask patients to help you test new ideas.
  • Learn together about what could improve health, cost, and care experience.
  • Such testing can happen as you work with individual patients, or be more formally structured by inviting individuals with lived experience to become members of your improvement team.
  • Conduct focus groups on specific topics to get deep patient perspective to guide your care redesign process.
  • Engage individual patients in testing changes. Examples include:
    • Co-visits with primary or specialty care providers.
    • Meeting in a new location.
    • Trying a new method to establish goals. Once a relationship of trust is established, you can say, “We are working on making (your goal) better, would you be willing to try this new approach (describe)? It is okay if today is not a good day for trying something new.”

Overall tips and guidance

  • Test whether your enhanced care model is capable of addressing the multiple determinants of health for your population with complex needs and high costs. As you begin working with five individuals and then expand to 25 individuals, observe if the interventions you are using are impacting identified determinants of health:
    • Are patients accessing shelter, food, counseling, or connecting with their support system more frequently?
    • Is the level of patient self-management improving? Are patients more engaged in their care?
    • Are patients able to problem-solve around barriers?
    • Are patients able to engage with care providers who can help them decrease their use of high cost health care services?
    • As you bring interventions to address identified root causes, track if they are supporting the individuals towards greater function, health, and confidence. If the interventions do not seem to help, it is likely that new interventions need to be tested.
  • Look for ways to address the patients’ non-medical needs, alongside their medical needs. For example, a health care provider may help manage diabetes in a homeless person by providing appropriate doses of insulin (a medical need) and providing a safe place to keep the medicine cold (a non-medical need), or an individual may need to get reconnected with loved ones before they can address their depression and heart failure.
  • People in your chosen population with lived experiences of health care have knowledge that is unique and they can provide valuable insight to your team. They can become valuable members of your improvement team. When partnering with patients to develop your care model or participate in quality improvement team meetings, be mindful of their limited time and look for ways to compensate them for their time.