1. Develop a care model that fits the needs and assets of your population with complex needs and high costs, and aligns with your context.
  2. Prepare for care redesign by co-creating individualized care plans and learning alongside five patients.
  3. Develop your enhanced care model through iterative testing with 25 additional patients.
  4. Develop work processes to ensure consistent care delivery as the program grows from 25 to 125 patients, and beyond.

1. Develop a care model that fits the needs and assets of your population with complex needs and high costs, and aligns with your context.

Use your knowledge of your population with complex needs and high costs to develop an enhanced care model that meets the needs of your population.
  • Your care model should address the root causes of high service utilization among subgroups of your population with complex needs and high costs. Use the knowledge generated from your 3-Part Data Review process, and from working with individuals in your population with complex needs and high costs, to understand their assets and needs and guide changes in care delivery.
  • As the team reviews the 3-part data review results and early experiences serving the population, strategize about care redesign by considering:
    • What changes are suggested by what you learned in the 3-part data review?
    • What changes worked well with the first few patients?
    • Organize the identified needs and subsequent services needed in the needs/ services/partners grid.
  • Individuals in your population with complex needs and high costs are currently being cared for either in the health care system or in community organizations. Think about how to care for them differently to achieve better outcomes, improve their experience of care, and lower health care costs.
  • The development of your enhanced care model is a learning process. Most organizations start with what they have — for example, primary care, an existing care management program, an existing partnership — rather than build from scratch. Consider unexpected partners. For example, in recent years, some Fire Departments have seen a strategic need to develop enhanced care models using a robust design process.
  • Steps in developing your enhanced care model include:
    1. Consider these questions:
      • How do you currently care for this population?
      • What seems to be working, and how can the team build on that?
      • What is not working?
    2. Explore what has been successful in other organizations similar to yours and organizations that successfully serve patients with similar assets and needs. Review the literature and do some site visits.
    3. Develop a prediction or “working theory” of what your enhanced care model will need to deliver and how to deliver it based on your current knowledge.
    4. Begin to learn what works and how to deliver the care using robust quality improvement methods and the 5x method (start with 5, then increase to 25, 125, 625, etc .) of working with patients. Ensure that the team has the latitude and support to test different kinds of interventions, roles, and workflows. The specifics of the care model will emerge as you move forward.
  • Several generic care models have emerged for population segments with complex needs and high costs. Each model has different strengths and concerns, which are outlined in the table below. Within these models, there can be substantial variation in staff allocations, staff roles, and available care interventions. Partnering with primary care is necessary regardless of which model you choose since primary care teams provide ongoing referrals, have knowledge of patient history and context, and are the foundation of clinical care in the wraparound and community models.
Models, Examples, Definition Strengths  Concerns
Ambulatory Intensive Care, sometimes referred to as an Extensivists model

Example: Stanford Coordinated Care

In this centralized model, primary care services are structured to exclusively serve patients with complex needs and high costs.

Patients are served by an integrated, multidisciplinary care team that typically has responsibility for a panel of 200 to 400 patients. 

Care services are intensive, holistic, and customized to the assets and needs of the patient.

When needed, the care team connects patients with additional supports such as substance abuse, mental health services, food, or housing.

  • Specialized services are customized to meet the needs of the target patient population.
  • The patient establishes a trusting relationship with one small care team.
  • The patient receives needed services in one place, with other services coordinated seamlessly by their care team.
  • The care team is together, which supports high functioning and optimization of roles, including non-licensed staff, which can be highly optimized to help contain costs.
  • The care manager role can be filled by a licensed team member such as an RN or MSW, or by a non-licensed team member such as an up-skilled medical assistant or community health worker.
  • This model is expensive with specialized staff, facility costs, and small panels.
  • There needs to be enough demand for the service to support the costs.
  • It may take time to ramp up to serve enough patients to support the costs, thus potential return on investment (ROI) may be delayed.
  • Patients typically receive primary care in an ambulatory intensive care unit, which means leaving a relationship with another primary care provider (PCP). This can be seen as competition by other PCPs.
  • Patients often leave ambulatory intensive care when they develop sufficient self-management skills, creating another transition back to traditional primary care.
Enhanced services wrapped around primary care base

Examples: CareOregon and Cambridge Health Alliance

“In this model, strong primary care is the foundation and location of care and enhanced services are “wrapped around” the patient and primary care provider team.

An identified care manager is assigned to each patient, organizes the needed assessments, co-creates the care plan with the patient, and is the designated liaison with other care team members, primary care, and other health and social services.

Caseload size is established for the care managers, including nurse care managers, social workers, or paraprofessionals.

In this model, enhanced care teams need to form strong, ongoing connections with primary care providers, with the goal of supporting them so that patients can return to traditional primary care.”

– Eleni Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Health Alliance

  • The patient relationship with the PCP and care team can be leveraged.
  • Patients receive enhanced care in their community or familiar setting.
  • When done well, the enhanced services reduce the burden on the PCP office, and can help PCP staff learn how to better manage patients with complex needs and gain more effective engagement skills.
  • When done well, primary care practices feel more supported in their work.
  • Embedding your enhanced care team into the traditional primary care clinic (a “co-located” model) can increase referrals, communication, and care coordination with other providers that work with your population.
  • Not all patients with complex needs     and high costs have trusting relationships with a PCP and not all have a PCP.
  • The partnership with the PCP office     has to be effective, which takes intention, time, and building a relationship with the PCP. This may be challenging for some organizations. For example, a health plan may be successful with the practices that are close to health plan headquarters, but partnering with practices more regionally distant may prove challenging and require different strategies.
  • There is wide variation in the ability, interest, and desire of different primary care practices to do the work necessary to coordinate, communicate, and partner with external care programs for patients with complex needs and high costs.
Community Coalition

Example: Camden Coalition

In a community coalition model, an organizing entity, ideally an entity experienced as neutral, supports other community entities that work together to improve wellness and quality of life.

Entities commonly found in community coalitions include faith-based organizations, housing or tenant groups, social service agencies, mental health providers, employment groups, and local health care providers.

This model entails development of common goals and ways of working together, establishment of a leadership structure to move the work forward, and identification of sustainable funding is paramount.

This model is most often used for a population that is defined by geographic boundaries and is highly influenced by a body of work known as collective impact.

  • When done well, this model leverages all community resources to support individuals with complex needs and high costs.
  • The model is most focused on impacting the social determinants of health, which are big drivers of poor health outcomes.
  • Individuals receive what they need in their community.
  • The coalition and the resources it leverages can be a strong resource for your enhanced care model.
  • Establishing an effective coalition, takes time, intention over time, humility, willingness to listen and adapt, continuous open communication, and creating a shared purpose.
  • Finding financing to support the work, especially over time, can be challenging.
  • Different organizations in the community may benefit or lose money as the work progresses.
  • A neutral facilitating organization is needed to keep the coalition moving forward together, and this role of neutral facilitator is very challenging to carry out consistently over time.
  • Community coalitions rarely form to serve one segment of a population, such as individuals with complex needs and high costs.

Identify the staffing structures and care partnerships that will support delivery of your enhanced care model.
  • Identify who will be part of your core care team, where the members of your core care team will be located, and how these care team members will be connected to traditional primary care. Determine your staffing and partnership approach based on the assets and needs of the target population, and the capacity needed for different types of services.
  • Identify your core care team:
    1. Review what you have already learned about the assets and needs of your target population, including the results of your 3-Part Data Review, to understand the types and prevalence of bio-psycho-social needs.
    2. Care teams that work with populations of patients with complex needs and high costs typically include some combination of the following staff roles: care manager, nurse, social worker, community health worker, and physician. Core care teams can also include full- or part-time staff in these roles: behavioral health specialist, pharmacist, dietitian, pain management specialist, or other staff roles.
    3. Anticipate which staff roles are an integral part of your core care team, and which should be seen as partners to your care team, based on the most prevalent needs of the target population. For example, if your target population has a high prevalence of behavioral health needs, then a behavioral health provider should be a part of your core care team. If there is a high prevalence of complex medical conditions, then more medical staff may be needed. If poverty is a high need, then community health workers may be most appropriate.
  • Consider these guiding principles when determining where to locate your enhanced care model staff:
    1. Relationships: Building effective working relationships with primary care practices, patients, and community resources is crucial to success.
    2. Effectiveness: Consider what interventions your organization can best support to ensure the effectiveness of your enhanced care model.
    3. Efficiency: Consider the efficiency of staff and resources in relation to your projected return on investment.
    4. Co-location of Care: Multiple services can occur in the same physical space and can span the continuum of care.
Possible Location of Enhanced Care Team Benefits Challenges Considerations for Success
Embedded in primary care
  • Facilitates the formation of strong relationships to support the program. Program staff have knowledge of and relationships with community partners.
  • Program staff can work with patients in their community or familiar environment.
  • Supports the primary care practice in providing better care to these individuals.
  • Facilitates more frequent face-to-face interactions with patients.
  • Enhanced care staff need to integrate into the clinic’s workflow and culture, yet maintain a focus on a few individuals.
  • There needs to be sufficient volume of patients in any one practice to justify the cost of embedding staff.
  • Support from the central “office” (e.g., health system or health plan) needs to be reliable and robust to ensure staff are supported and desired benefits for the PCP and the program are met over time.
  • Embedded care management staff can become isolated in their challenging work.
  • A clear, shared vision and incentives with PCP and clinic staff for the purpose of the enhanced care program.
  • Strong support is needed from the central “office” for enhanced care staff hiring, training, ongoing support for difficult cases, and flow through the program.
  • Ensure enhanced care staff have what they need to function in the office (a desk, computer, phone, private space, etc.).
  • Ensure regular joint case conferences on shared patients.
  • Ensure regular communication about shared patients with PCP and others involved in patients’ care.
Centrally located in a home office to serve a geographic area that is relatively nearby (e.g., a city or county)
  • Enhanced care staff can become a high-functioning team, supporting and improving the work in real time.
  • There may be less overhead expenses (depending on resources needed to engage patients and providers farther away).
  • Care managers are seen as outsiders, coming in once in a while, making it harder to build working relationships.
  • Care managers and enhanced care staff most likely need to travel to meet with patients, PCPs, and community resources, which will impact caseload and costs.
  • If the central program also needs to reach patients farther away, the organization will need to create local enhanced care teams in those areas.
  • Centralized staff will have fewer connections with local resources.
  • Care managers have to build relationships with a variety of PCPs they do not see often.
  • Care managers from a central office are not able to visit the practices and community organizations often and become even more of an outsider.
  • Program staff should meet with PCPs, clinic staff, and community organizations frequently.
  • Ensure regular joint case conferences on shared patients.
  • Ensure regular communication about shared patients with PCP and others involved in patients’ care.
  • Create enhanced care teams in the local areas.
  • Explore how to connect virtually to support regular communication about processes and patients.
  • Establish regular virtual case conferences.
Tips and guidance to develop a care model that fits the needs and assets of your population:
  • Learn about care models from others who are doing this type of work. Visit sites with best practices and talk with their organizational leaders, care teams, and care users to see if their work can be adapted to your setting.
  • A care manager is an integral part of any enhanced care model that targets populations with complex needs and high costs.


“We are seeing early life trauma as a predictor of high utilization. It’s pretty crucial to understand how traumatized patients are and the impact of early life trauma. It’s probably the leading reason to be an over-utilizer and, for example, not every homeless person over-utilizes the hospital. In fact, very few do. Not every person with addiction goes to the hospital; in fact, most addicts never go to the hospital. Not every person with mental illness is in the hospital. Not every person with a severe illness goes to the hospital. Very few do.There are all these stereotypes about who your high utilizers are. The one really underlying common theme that we’ve seen are extraordinary levels of early life trauma in childhood, and often overlapping later life trauma. We’re not trained well for this. We don’t like to talk about it and we try and medicalize interventions, and the reason they are over-utilizers is because we keep medicalizing the intervention. It’s really common to hire the wrong nurses for this work. It’s really common to have the wrong doctors involved. It’s really common to have the medicalized social workers get involved and frame this as a traditional nurse-driven care coordination and we’re going to make a care plan and tell them what to do. ‘Do what we say, see your doctor, take your medicine’, and those constructs that we’ve seen don’t work. It’s a real misunderstanding of what’s causing people to go (to the hospital), how they got to this point in their lives, what we need to do to help them in the journey.” Jeffrey Brenner, MD, Executive Director, Camden Coalition of Healthcare Providers

2. Prepare for care redesign by co-creating individualized care plans and learning alongside five patients.

The key characteristic of populations with complex needs and high costs is the juxtaposition of poor health outcomes and high health care utilization. Despite participating in many health care interventions, people in these populations often continue to struggle with poor health. As a result, your care team will need to learn what to do differently and how best to meet health care needs by co-designing care delivery methods alongside individual patients.

Co-designing an effective intervention is an iterative process that will take time and numerous cycles of improvement. The 5x method of working in multiples of five patients (e.g., 5, 25, 125, 625, etc.). can enable your improvement team to learn deeply on a small scale with a lower investment and low risk of failure. Existing staff can often fit small tests of change into their current workload.

Co-create and carry out care plans with five patients from your target population to identify effective methods for engaging patients and providing services.
  • Your care team’s assessment of the person’s goals, assets, and needs will be the foundation for developing an effective care plan. Consider how staff behaviors and flow of care can be improved to build upon a patient’s existing assets and meet their needs. Review Health Quality Ontario’s (HQO) coordinated care plan template. 
  • Identify and build upon assets. Assets are the resources that help people achieve and maintain health and wellness. They may include community assets such as homeless shelters, the faith community, free medical clinics, walking trails, or other community resources. Identify assets more specific to the individual including personal goals and motivations, family support, other social support systems, health insurance, and other benefits the individual may qualify for.
  • Strive to deliver “perfect care” for these five individuals as a way to learn about what it takes to make a significant impact.
  • Learn what to do differently by trying out different ways to:
Test methods to effectively engage five patients from your target population at different stages of the care journey, including recruitment, engagement, and flow through the enhanced care model.
  • At this stage, test a variety of different strategies, including those very different from normal care.
  • Answer the following questions to learn what methods work most effectively for your population:
    • Who will connect with the individual to set up a first meeting?
    • How will you connect with the individual to set up a first meeting? Some care teams use phone or written outreach, while others use warm handoffs from a PCP or another trusted person, or meet individuals where they are receiving acute care.
    • Will the individual work with the care manager or also with a social worker, nurse, or other staff person?
    • Where will care providers and patients meet? Consider whether a member of the care team can meet the individual in the clinic, in their home, or on their own “turf” where they feel most comfortable.
    • How will the care team manage the interaction to establish trust? Some examples include focusing on what matters most to the individual, consistently delivering what you promise, allowing staff the time to build relationships, and hiring staff with high empathy.
    • How and when will the care manager or care team assess needs and assets and work with patients to co-create a care plan? Many care teams find that this process occurs over several visits.
    • What language works? Identify messages that resonate with the individuals in the chosen population and determine words and phrases that disillusion or disengage patients.
    • What services are required to address the needs of the individual? Care teams are often trained to provide multiple interventions and care protocols.
    • How will you leverage the assets of the individual and their community? Consider how community assets such as religious supports, housing managers, Boys and Girls Club counselors, and other partners can support the individual in achieving their co-created care plan.
    • What does it take to create an effective relationship between individuals and their primary care and other care providers?
Identify what you are learning that informs your care design or redesign.
  • As you test and carry out co-created care plans with your five patients, document the tasks or steps needed to achieve the goals laid out in the co-created care plan.
  • Identify who took responsibility for each task, including the patient, their informal caregivers, program staff, and community partners.
  • Note the similarities in the services required and how you needed to deliver the services (e.g., did phone calls work or did you need to make home visits?).
  • Begin to outline how your care model works and the type of interventions that are needed to achieve success with your target population.
Tips for engaging five patients in your target population to inform how you might redesign your care model:
  • Help individuals in your chosen population identify life activities that bring them meaning and help them build those activities into their daily lives.
  • Identify what matters to an individual or makes them feel happy, alive, and connected to the community. Build on activities that are working well for the person, and help them reconnect to elements they would like to rekindle.
  • Consider how to provide whole person care that addresses social, physical, and behavioral health goals and actions.
  • Think broadly about what people need to achieve their goals and build a healthier life (identify touch points and services).
  • Use motivational interviewing or other suitable approaches to identify life- and health-related goals that the patient is willing and able to address.
  • Discover how life goals and health goals are connected.
  • Start with small action plans that can set up individuals for success over time and build confidence to manage their health.
  • Discover how to optimize care for people with complex needs and high health care costs by providing the right care, at the right time, with the right provider, at the right location.
  • Involve any preferred support people in care planning and/or carrying out the care plan, as determined by the patient.
  • Celebrate patient-identified successes and problem-solve quickly.

“We started with the family care clinic because it already exists to address complex primary care needs. As we started to engage clients in a different way, it became evident what we would need to do differently. For example, the health coach approach — identifying other services we needed to surround that person with — that’s where we started to engage addiction, mental health, and home care because our clients would identify who else they also are working with. Our model has been evolving out of work with a small number of patients, then a bigger number, and that’s how we start to figure out what the next step is. It’s kind of like driving in the dark when it’s foggy with the headlights on, and you can only see so far in front of you.” Jo Ann Beckie, Executive Director, Integrated Quality Management, Alberta Health Services - Calgary

Tips and guidance to prepare for care redesign:
  • The important thing at this stage is to get started and begin learning. Do not “let the perfect be the enemy of the good”! You can identify these five patients:
    • From the interviews with patients you conducted to learn more deeply about the assets and needs of the population
    • From referrals from PCPs or their care team members, staff in social service agencies, and behavioral health staff
    • From utilization reports
  • At this stage, identify one or a few staff members who are interested in learning and testing how to provide care differently and free up enough of their time from normal duties to work with the five patients.
  • Strive to do all that is needed to give these five patients “perfect care.” In this process, you will learn a lot about navigating through the system, engaging difficult-to-engage individuals, and the barriers your patients face.
  • Try really different things. If you only have office-based care, test doing home visits; if you only do phone care, test meeting the patient at the office visit or while they are in the hospital; if you always put the medical agenda first, test just listening first. The goal here is to learn what you have to do differently to get much better outcomes.
  • Begin to understand what may or may not be sustainable at a larger scale.
  • Explore bringing high-intensity, high-resource interventions to individuals who have very high health care costs and determine if there is a good return on investment for some individuals. For example, for an individual who frequents the emergency department at an extremely high rate, having a daily interaction may well help the individual stabilize their situation and be worth the staff costs.


“Don’t do what you’ve done before because it probably hasn’t worked if you still have a segment of people that are very high cost. Start with the notion that you need to do something different than you’ve done before. Be very open to that. Break out of the mold of traditional case management models or medical models and think really broadly about all the different ways we refer to patients — who are individuals and people, residents of our communities — and all the different touchpoints and services they may need to help them build a healthier life for themselves. Often that means thinking about partnerships with community-based organizations or social service agencies that are not always thought about as part of the health care system.” Rebecca Ramsay, BSN, MPH, Executive Director, Population Health Partnerships, CareOregon

3. Develop your enhanced care model through iterative testing with 25 additional patients.

As you move from working with five patients to 25, it is likely that your original care model design will remain consistent, but the iterative cycle of scaling up to serve a larger number of people will help you refine what needs to be included in your care model and how to deliver the care.

Based on your experience with five patients, identify useful interventions and develop a plan to test those interventions with 25 patients.
  • Keep in mind what you learned in the three-part data review process about what individuals want in their care and what has been effective or ineffective for them in the past. Learn about what was different when health was better.
  • Continue testing all of the promising elements of the care model that were identified with the initial five patients. Learn what interventions are effective and ineffective and how to reliably bring effective interventions to patients. Determine how to:
    • Engage patients in care.
    • Help patients move though the different stages of their care journey (including recruitment, engagement, flow through the enhanced care program and, potentially, graduation).
    • Support patients in building self-efficacy and self-management skills.
    • Partner with appropriate community and health resources to support patients’ needs.
  • As part of this process, track outcomes for the individuals you are working with to build learning. Identify whether some subgroups need different strategies for identification, engagement, care, and partnership. For example, homeless young people may need different engagement strategies than people from an immigrant community.
  • During your testing process, build on the interventions that drive better patient outcomes and identify which care elements and services are crucial to success. When you feel confident in your interventions (based on care outcomes of the engaged patients to date, and patient guidance), define the elements of your care model.
    • Document if and how your care model will include care management, system navigation, pharmacy support, primary care, behavioral health, community resources, and social or other services.
    • Document how different people play a role in the care model, including people using the care system, their families and informal caregivers, as well as the roles of different staff, care team members, and partnering organizations.
  • Leverage new resources that meet the needs and build on the strengths of your target population, such as: health education, integrated behavioral health care, care coordinators, community health workers, co-located pharmacy, and strong links to community programs.
Begin to establish reliable work processes and systems.
  • Continue to test strategies for each stage of the care journey: patient identification, engagement, assessment strategies, care planning, flow through the enhanced care program, and evaluation.
  • Identify strategies for individuals in various stages of readiness to engage (i.e., not ready, considering, ready, and those who move in and out of engagement).
  • Define the roles and responsibilities of each member of the enhanced care team:
    • Outline clear job tasks and role delineation for each member in a multidisciplinary team.
  • Adjust your staffing level to meet the enhanced care program’s needs:
    • Tailor staff mix and disciplines to meet the needs of your target population. For instance, social workers and psychiatric nurses may be a better fit than medical nurses in a population with high behavioral health needs; community health workers or non-licensed health navigators are often more effective at engaging patients around community resources, navigating the health care system, and problem solving.
    • Optimize the roles of each care team member, including non-licensed staff, to deliver the needed care.
    • Begin to understand the drivers of an eventual caseload mix, including criteria for entry, amount of staff time needed to recruit individuals into the program, engagement rate, acuity and persistence of issues that will need time and attention, and criteria for graduation from the enhanced care program.
  • Document routine workflows:
Develop systems to ensure staff have the necessary expectations, training, and skills to productively engage with patients with complex needs.
  • Proactively consider staffing needs as the enhanced care program grows from serving five people, to 25 people, and beyond. Determine the right level of staffing and necessary skills during this design phase, and work with stakeholders of your enhanced care model to identify criteria for beginning the hiring processes for additional staff.
  • Hire the right people:
    • Hire strategically. Determine the tasks that need to be done, skills needed to perform those tasks, and the desired outcomes of the staff role. Consider how non-traditional roles or non-licensed health workers can bring in new skills to your enhanced care team.
    • Staffing needs are connected directly to the assets and needs of your target population. Optimize staff roles and responsibilities to ensure that all staff are working at the top of their licensure. For example, identify what clinical experience is needed by your staff, and also what level of lived experience of health may be needed to connect with patients (e.g., community health worker role). Diversity of staff experiences and expertise may improve patient engagement and help manage costs.
    • Consider what staff characteristics are important for your enhanced care model. Most enhanced care models find that strong compassion, empathy, and communication skills are important. For example, the ability to listen and connect with people is often a paramount trait in the care manager role and is typically shared to some degree by every member of the care team.
  • Train staff:
    • Identify the critical skills that your staff need and establish training protocols. Many of the skills needed in these programs are not skills used in traditional health care settings. Train based on the needs of the patients and input from staff. Common trainings for enhanced care programs include trauma-informed care, motivational interviewing, substance abuse treatment options, pain management, advocacy skills, mental health conditions and treatment options, trauma stewardship, chronic disease management, goal setting and care planning, and connecting with social services.
    • Determine how to support and deploy staff to deliver new types of interventions, including home visits, goal setting that starts with the patient’s goals, advocacy and navigation through the health care system, and supporting the individual work through barriers to their engagement with the care plan.
    • Carry out intensive onboarding of new team members. Role model and practice how staff interact with patients, including healthy relationship behaviors. Some programs train staff through a combination of didactic education, shadowing other staff, and a period of being shadowed. Others provide mentor programs for new care managers.
    • Provide ongoing training, supervision, engagement, education, and re-education to all staff.
    • Seek training from technical assistance providers when your organization is unfamiliar with new ways of working with your target population. For example, several organizations provide formal training on how to incorporate community health workers into a care model, trauma-informed care, and motivational interviewing.
  • Support staff and monitor for and protect against burnout:
    • Create a culture of collaboration and support within your care team.
    • Create a structure to support workforce vitality and avoid burnout. For example, some programs urge staff to take time off for self-care and include mindfulness exercises, meditation, and gratitude in their regular meetings. Other programs ensure a strong support system for the daily work, with real-time help in problem-solving when crises arise.
Develop process measures to track performance of key tasks.
  • Establish data collection systems to track process measures based on staffing requirements, job descriptions, workflows, and quality standards. Begin by identifying and tracking the core activities that you expect will create change in your enhanced care model. Your care team can use active daily management to ensure that staff are spending time on the activities that are likely to have the greatest impact on patient outcomes.
  • Understanding these process measures will help your team know if it is implementing your enhanced care model as it was designed. Process measures to consider include:
    • Number of individuals recruited into the enhanced care model
    • Amount of time between service referrals and appointments
    • Percent of individuals engaged in the enhanced care model
    • Frequency of meaningful contact (i.e., documented two-way conversation or correspondence)
    • Number of individuals working with a health coach
    • Number of patients assigned to each staff member (e.g., caseload)
    • Location of care delivery
    • Completion rates of standardized assessments
    • Duration of care visits
  • Your improvement team can use health information technology to enable care management, remote monitoring and analytics, and to provide timely and reliable information on use of health care services.
  • As you do this work, test ways to take expense out of the delivery system. Begin to understand your staffing model and start to model the expenses versus projected savings. Explore whether the care model can successfully include staff with non-traditional roles, such as community health workers, or can assign non-traditional roles to traditional staff such as medical assistants. Some teams have found that deploying non-traditional health workers to coordinate care, co-create care plans, and help patients navigate the health and social care systems can enable other care team members to work at the maximum of their certification.
Tips and guidance to develop your enhanced care model through iterative testing:
  • Review how Stanford Coordinated Care  and CareOregon developed and supported their staff to effectively carry out the enhanced care model.
  • Provide regular opportunities for team members to learn from each other. Highlight specific skills of staff in meetings and invite team members to share their care processes.
  • Design a team-based approach to overcome existing health care silos.
  • Anticipate that non-licensed health workers will need support from others on the care team and will need training to maximize their contribution to the patient and care team.
  • Build mentor, peer, or guide roles into the care team to support and deeply engage patients.
  • Ensure that staff are working at the top of their skill-set. For example, some enhanced care programs train medical assistants to be “care support” providers and others develop community health worker and patient navigator roles.
  • Recruit staff from organizations where candidates are likely to be aligned with your organization’s values and mission.
  • Re-train staff to take on different roles in the enhanced care model. For instance, some programs give more responsibility to staff who embrace the vision and workflow of the enhanced care model, while less engaged staff are transitioned to traditional programs and roles.
  • Invest in the time and resources needed for your care team members to form relationships with patients.


“It’s so important to identify the right people to do the work. Who you hire into the position of care manager is really important and training them well is also important. We have nurses and social workers in our organization. We put social workers in the mix for two reasons. One is we have a population with pretty high behavioral health needs and so we want people who are comfortable working with these individuals. And two, we find that social workers are very effective for the approach of starting where the patient is.  This is a core social work concept, which we believe is central to engaging a patient and making an impact.

Really listening to patients and understanding what’s important to them, that’s our starting point.  Patients have to be able to say, “This is what I want to do. I’m willing to work with you in this regard, because this is an outcome that I can relate to.” I think that having members from different disciplines who can work well together and trust each other is essential.  Selecting the right mix of staff for your population is key. It’s tailoring the type of individual employee you want as your care manager to the population you intend to serve.”Eleni Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Health Alliance

4. Develop work processes to ensure consistent care delivery as the program grows from 25 to 125 patients, and beyond.

As you move from working with 25 to 125 patients and beyond, your improvement team should standardize care processes, communication processes, and data reporting processes. This work will help your improvement team develop reliable and efficient methods for delivering appropriate care, and help your patients and care team consistently achieve their intended results.

Standardize your care processes to ensure reliable care delivery, including recruitment, assessment, engagement, and step-down to usual care.
  • Include processes for maintaining appropriate staff caseloads, a vital workforce, and ensuring a successful patient journey through your enhanced care model.
  • Maintaining appropriate staff caseloads:
    • Determine the capacity of your program to serve patients in recruitment, active, and maintenance status. Deploy your staff to provide optimum effect.
    • Establish the caseload mix by understanding criteria for entry and graduation, amount of staff time needed to recruit individuals into the program, and acuity and persistence of issues that will need time and attention.
    • Caseload is likely to vary across enhanced care programs for populations with complex needs and high costs depending on the frequency of patient contact, the intensity of your intervention, the composition of your care team, the assets and needs of your patients, and the mix of patient severity.
    • Create a dashboard that displays the status of each caseload so the team can monitor caseload fluctuation. Manage staffing plans by setting a target for staff caseload expectations that incorporates the number of active patients and the number of patients in outreach status and/or maintenance status.
    • Manage throughput in care. Deploy clinical supervisors to meet one-on-one with each staff on a weekly basis and review what is happening with each patient.
  • Patient journey through care:
    • Titrate care to meet evolving needs of patients; step-up and step-down in intensity of care, as needed. Identify criteria to shift a care plan from enhanced to maintenance levels of care.
    • Define ways for the care team to keep track of individuals after step-down to maintenance levels of care.
    • Define how individuals in maintenance levels of care are supported and flagged if their status changes.
Standardize your communication and data reporting systems to create ongoing opportunities to improve the care model.
  • Your improvement team can establish reliable communication workflows within and across care team members, other clinicians, and partners. Your team can also establish reliable and real-time data collection and reporting systems that give your improvement team and stakeholders access to the information they need to learn and make decisions about the enhanced care program.
  • Some teams find that an “active daily management” process can help ensure that the most important activities get the most attention from team leaders and that barriers to delivering these services are quickly removed.
    • Active daily management is an approach where leaders and staff members take time each day to evaluate their progress toward meeting the organization’s improvement targets, measure how they compare against the organization’s overall progress, solve problems in the care model or workflow, and escalate problems to identify immediate solutions.
    • With active daily management, care teams can stop workflows, operations, and standard work to discuss problems in the flow of care or in the care system, to understand the extent of these problems, and to offer solutions that can be tested rapidly.
  • To facilitate the process of active daily management, teams can:
    • Create visual wall displays that show goals and standards.
    • Track key metrics.
    • Conduct daily huddles or brief meetings to identify problems that need to be addressed.
    • Receive direct observation of work processes and support for improving performance relative to standards.
  • Some teams find that weekly team operations meetings help improve work processes. Discussions focus on what is working and what is not working, how changes can be enacted smoothly, signs of staff burnout, communication issues, and how the team is doing relative to their evaluation metrics.
Tips and guidance to develop work processes:
  • Weekly meetings can support staff in building self-reliance, including always having an active goal the team is working toward with each client, and encouraging forward progress and movement through the program.
  • Continuous communication at every level is important. It should be positive, while accepting the challenges that exist.
  • Keep an open mind and open lines of communication.
  • Create a multi-faceted ongoing learning process.
  • Clearly document processes and make work “easy to do.”
  • Recognize that many victims of trauma also work in the health delivery system, and programs should incorporate purposeful debriefing sessions and support to try to avoid re-traumatization.
  • Learn your way to the right caseload or panel size, and don’t overpromise. Care teams often overestimate the number of patients that they can effectively serve. Caseload sizes will differ depending on the characteristics of your program. For example, some organizations provide a “light-touch” approach with the goal to transitioning patients quickly to other services. In contrast, other enhanced care models work much more deeply with a patient.

“Case managers spend a lot of time exploring where to go when they face issues. This includes documenting what services are available and building on existing knowledge rather than recreating the wheel every time. In order to do this, case managers have a standing item in their bi-weekly meetings where clinicians discuss what was successful that they did and how they did it. This provides information for other case managers to follow.”Jo Ann Beckie, Executive Director, Integrated Quality Management, Alberta Health Services - Calgary