Lessons from the Field

jeremylongDenver Health is an integrated safety net health care system in Denver, CO.

“Our Ambulatory Intensive Care model has enabled us to really draw on our workforce and identify some of the particular pieces of an interdisciplinary team that could deliver the right type of care — the high-level, team-based care needed for patients with complex needs — and become facile in delivering the care, not taken aback by the extreme needs of every patient in the clinic. For our setting, having a separate clinic gave us a space to test a lot of different theories and interventions (And it seems to be working for our patients and program goals).” Jeremy Long, MD, MPH, Associate Professor, Division of General Internal Medicine with the Denver Health and Hospitals, Department of Medicine (edit)

Co-Location of Care Lessons from the Field:

metge-photoWinnipeg Regional Health Authority (WRHA)
is one of five regional health authorities in Manitoba, Canada.

“What has helped our partnering with community social service providers is having that grounding in Community Area sites, for example, Family and Social Services staff. The partners needed are literally just a walk down the hall, or accessible with an email. Since we have been physically located with many of the internal partnerships we need — Community Mental Health, Housing, those kinds of things — we have a very good grounding for our work. Physical and even virtual proximity through relationships is what ends up being the most effective. Co-location is all about relationship building and if you are talking with other teams (on a regular basis), that’s so important. If you can’t be co-located, you then have to reach out in a virtual sense (to build those relationships).”

Colleen Metge, MD, Director, CHI Evaluation Platform Division Quality & System Performance, Winnipeg Regional Health Authority


co_ramsay_rebecca_-5x7_3-002CareOregon is a non-profit Medicaid health plan located in Portland, Oregon.

“We created value for providers by hiring and training a new workforce that they’d never had before and embedded them in their care team. We call that workforce “health resilient specialist” in this particular program. They are Masters level social workers who have careers built on working with disadvantaged populations, doing community outreach and community-based care, understanding the effects of trauma, poverty, mental illness, and substance abuse. The trick was for CareOregon to pay for that staff, clinically supervise them, train them and support them, but because they are embedded in the clinic, they are viewed by the patient and by the clinic staff as part of the primary care team. They are not an outsider coming into the clinic every once in a while. They have a workspace at the clinic and that’s their hub, and then they serve clinic patients by going out into the community.”Rebecca Ramsay, BSN, MPH, Executive Director, Population Health Partnerships, CareOregon


elenicarrCambridge Health Alliance is a public safety-net health system located in Cambridge, Massachusetts.

“A key success factor for us is having care managers directly embedded in the primary care practice. Using this structure, care managers work side-by-side with doctors, nurses, and other health center staff to help our program achieve the Triple Aim.  Care managers have office space, a desk, and a computer. They participate in meetings with other practice staff, and their roles are flexible so they can attend home visits or visit a patient in the hospital or a senior center. Their role is distinct from routine clinic staff and we worked hard to maintain that distinction by being clear about the goal of their work and the activities they should be doing versus the activities that are best done by others in the clinic. When that’s well-articulated and prioritized, clinic leadership is more likely to buy-in to the role and that’s extremely important to the success of the model.” Eleni Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Health Alliance

diane-craig-mdKaiser Permanente Santa Clara Medical Center
is a general medical and surgical hospital in Santa Clara, CA. The following is a quote from a team at Kaiser Permanente, Santa Clara, describing how they learned their way to the right staff.

“Currently we have a community connector or a navigator type of person. We’re still working on the job code and job title, and we’ve been working with the nurse practitioner. This may not be our future model, but this is our current piloting model. We recently added an LCSW and then a PCP to the team because we found that a number of the patients who were not progressing toward their goals or were kind of stuck, had a psychiatric component that was beyond the scale of the people sitting at the table at the time. As we find similar issues cropping up, that’s when we’re bringing in the extra resource to see if they can help us address the issues. And we’re still figuring out if we need to have them as a full member of the care team or more of a consultant role. We are trying to learn what our perfect or ideal team is as we go. We will probably also need a pharmacist as an ad hoc care team member.”Diane E. Craig, M.D., F.A.C.P, Assistant Physician-in-Chief, The Permanente Medical Group, Santa Clara Medical Center


metge-photoWinnipeg Regional Health Authority (WRHA)
is one of five regional health authorities in Manitoba, Canada.

“Here’s what our care approach looks like in action. First, there is collaborative care planning and goal setting with patients, family, and caregivers. Once we understand the needs of the individual patient, then there is intensive case management with interdisciplinary team-based care, care coordination, and communication with existing partners. We actually have a visual around patients’ needs, services required, and partners required. Upon achievement of goals patients are transitioned to appropriate community resources, which may include primary care.

Once the case coordinator has narrowed in on the client’s goals for care, the services are determined. We understand that the most successful strategy is based on understanding what the patient’s needs are and then going out and finding the services that will meet those needs. We have built relationships with a variety of community partners so our patients can get their needs met. One of the nurse practitioners frequently asks, “OK, how do we find a way to say yes to this person? How do we find a way to help this person with whatever their most pressing need happens to be?” I think that has been the spirit of going out and establishing these connections with community resources.” Colleen Metge, MD, Director, CHI Evaluation Platform Division Quality & System Performance, Winnipeg Regional Health Authority