1. Develop a trusting relationship with each patient to support positive health outcomes.
  2. Adopt patient engagement methods that build self-efficacy and patient confidence to manage their own health.
  3. Recruit patients for the enhanced care model.
  4. Assess each patient’s experiences, strengths, and needs.
  5. Co-create individualized care plans with each patient.
  6. Align one care manager as the primary support for each patient.
  7. Build engagement skills among the care team and support the care team in carrying out effective engagement methods.
  8. Develop work processes to engage patients throughout the care journey.
  9. Foster peer-to-peer support among patients. 

1. Develop a trusting relationship with each patient to support positive health outcomes.

Why focus on developing a trusting relationship?
  • Individuals with complex needs and high costs have, by definition, engaged in a great amount of health care but still experience poor health outcomes. It is natural for someone in this position to be wary of spending more time with another care team participating in more health interventions.
  • Some people in this population report negative experiences with health care professionals in the past, leaving them feeling disrespected, devalued, and unmotivated to partner with health care. All of this underscores the need to revolutionize patient engagement — we need new ways of reaching this population, tailored specifically to support their needs, that is different from the care they have previously experienced.
  • The core intervention for individuals with complex needs and high costs is the development of a trusting relationship between a care manager and the patient. This supportive relationship grows and develops over the course of the care journey and can deeply impact the patient in many ways: sustaining momentum toward goal attainment, helping the patient develop self-management skills, and offering invaluable hope for the future and belief in the patient’s abilities.
  • All of this, along with the knowledge that someone on the care team truly knows and understands them, supports patients in making changes that will improve their health outcomes. Begin at the first encounter with the patient: listen, express genuine interest and concern, thank the person for the conversation, and use open body language. Listen to individuals impacted by CareOregon’s Health Resilience Specialists developing a caring, trusting relationship.
What does it take to deliver patient-driven care?
  • In recommendation five, we discuss the importance of co-creating individualized care plans with each patient. Oftentimes, this involves the care team partnering with the patient to achieve life goals that seem to have little bearing on health outcomes, such as reengaging in social activities or reestablishing family ties.
  • Following the path identified by the patient calls on a set of characteristics that must be practiced: patience around the pace of change, trust that the focus on life goals will lead the patient-provider pair to health interventions, discipline to stay the course, and a modest appreciation that the path is best-directed by the patient, regardless of the care team members’ years of experience and training. Start by spending time getting to know what’s important to the patient, what makes them feel energized, and what they wish for. The Camden Coalition’s Hotspotting Curriculum offers a deep view into this dynamic, as well as excellent training resources.
Strategies to build trust.
  • The co-created care plan is the cornerstone of care delivery, and it can also serve as the foundation of the lasting relationship between provider and patient.
  • Begin by inquiring about care preferences, including where and how meetings take place, offering to involve trusted family or friends in the care delivery process if preferred; recognize and celebrate progress; express genuine concern for and appreciation of the patient; and create opportunities for the patient to be recognized as an expert (in their care, a hobby, or other skill).

“Building trusting relationships is probably the most important and most critical thing that we do in the population we deal with, which is predominately a poor, Medicaid population with high rates of mental illness and addiction. There are a lot of issues that relate to poverty, things like housing and incarceration, that aren’t as common in other populations.

Our community health workers are our core design element to build trust. They are people with a shared lived experience who are hired from the community and trained extensively to work with these patients, to engage them and deliver different interventions. That’s a really critical piece of our program. I think the primary driver in that is how incredibly patient our community health workers are. These are populations that are so socially isolated; have such swirling complexity and competing priorities in their lives; are often disorganized because of that complexity and don’t perhaps have some of the coping skills that other populations might have; and are functioning under this overwhelming amount of pressure and stress due to their health conditions, addiction, family and social support issues, lack of caregivers, lack of housing and other foundational elements. When you think about that, they just need someone to take a step back and say, here I have some tools, I have some ways to help you; let’s organize some of your thinking around some goals, talk about your priorities, and organize that; and over time let’s work with you to develop the skills to do it yourself. What makes using community health workers so powerful is that we’re able to provide support from people who look like them, speak their language, are from their neighborhood — this engenders an immediate trust. We also specifically seek to hire workers who are “huggable” and empathetic and then train them in motivational interviewing to be even more so.

In addition, community health workers are able to provide a level of social support because, as a lower cost resource, they have more time per patient than a nurse in a clinic might have. They’re also able to extend the care into the patient’s home. I think that’s huge. They meet with patients in their homes, in the emergency department, in the hospital, under a bridge, if necessary. There’s a certain “wow” factor that comes with that because people aren’t accustomed to that. All of that creates a level of engagement that’s just absolutely critical. That’s really the first step. How do you engage these individuals and support them in ways that are going to be beneficial to them in the short term, so that they continue to be engaged going forward? That, to me, is the “special sauce” — the community health worker and the ability that they bring, along with the ways that we’re able to deploy them to meet the needs of patients.” Clemens Hong, MD, a primary care physician, and Medical Director of Community Health and Improvement for Los Angeles County, California

Tips and guidance for developing a trusting relationship with each patient:
  • Social workers, behavioral health specialists, and peer workers tend to be well-disposed to this form of deep personal engagement. Doctors and nurses may require “untraining” to develop postures that enable trusting relationships with patients to develop over time.
  • Observe the skills and outlook of individual care team members: some are likely skilled in engaging people, for others it does not come naturally, and some are committed to a hierarchical model of care delivery.
  • Shift care team members who are committed to a top-down care delivery approach to other work, as that orientation will not be successful with individuals with complex needs and high costs.
  • Elevate care team members who are skilled engagers, creating opportunities for them to share their engagement strategies and train their peers.
“Start with the patient or the client where they’re at, not where, as providers, we think we should start with them. It could be about their cat as their social support, and the cat is sick and they’re concerned about the veterinarian bill they can’t pay. Well, that’s where we’ll start.”Jo Ann Beckie, Executive Director, Integrated Quality Management, Alberta Health Services - Calgary


2. Adopt patient engagement methods that build self-efficacy and patient confidence to manage their own health.

Self efficacy is confidence in one’s ability to complete tasks, and in this context, to manage one’s health and life challenges. Care teams need to learn about the needs and assets within their population with complex needs and high costs and then use evidence-based engagement strategies to reach that population. A set of foundational engagement methods are described in this section. All methods are recommended evidence-based practices for populations with complex needs and high costs, and all require ongoing staff training and close supervision to ensure fidelity to the practices.

Self-management skills
  • According to the Mental Health Foundation, self-management skills are the capacities, methods, and strategies an individual uses to manage his or her activities or to reach health and life goals. Care teams work with each person they serve to develop self-management skills sufficient to manage their health and life challenges.”
Patient activation
Motivational interviewing
  • According to the Royal College of Psychiatrists, “motivational interviewing is a collaborative approach in which the helping professional guides the patient to explore and resolve their ambivalence about behavior change. It combines deep listening with gentle questioning to assist the patient to articulate the benefits and costs involved in continuing and changing a given behavior.”
Trauma-informed care
  • According to the Wisconsin Department of Health Services, trauma-informed care is an intervention and organizational approach that focuses on how trauma may affect an individual’s life and his or her response to behavioral health services, from prevention through treatment.”
  • It involves helping professionals learn about trauma, its biopsychosocial impacts, common triggers, and then using patient engagement methods that are tailored to minimize activation of a trauma response and maximize the development of trust. 
Tips and guidance for adopting patient engagement methods:
  • Learn the existing skills your staff have and identify gaps in their training.
  • Consider the needs and assets of your  population with complex needs and high costs and consider specific skills that could help them achieve their goals. For example, homebound individuals may benefit from more support from family and friends; individuals with multiple chronic conditions and depression may appreciate some simple problem solving support; homeless individuals may want support in finding their next meal.
  • Look for local opportunities for in-person training in needed skills, and search for online opportunities for follow-up training.
  • Review training resources for engagement skills. 

3. Recruit patients for the enhanced care model.

Defining recruitment.
  • Recruiting people into care is the first phase of engagement. The goal of the first encounter with a potential patient is to make a human connection with the person. This first encounter is a pivotal opportunity to communicate the potential value that the care team could bring to the person’s life. Remember that the medium is the message: the first encounter should be a meaningful human connection where the person’s dignity is respected.
    • Various skills aid in this, largely drawn from trauma-informed care principles, including the care professional using open body language, being aware of and avoiding potentially triggering circumstances and behaviors, engaging in deep listening, asking permission around each intervention, and expressing genuine gratitude for the individual’s participation and skills.
Deploying staff to recruit patients.
  • Some teams deploy the care manager to recruit new patients so that the relationship between patient and care manager can develop from the first encounter with the enhanced care model. However, this can pose challenges as the care manager tries to balance the current caseload with the time-consuming process of recruiting. Some organizations designate other staff skilled in engagement to serve as recruiters, who then provide a warm handoff to the care manager at the point the patient is enrolled in care.


“The first time you call a patient, how you present yourself is very important. You cannot start with, “Mr. Jones, do you want to be in a case management program?” They won’t even know what you’re talking about. They won’t know the value. You’ve got to prove to this patient that it’s worthwhile. When we call patients, we say, “This is Joanne from Dr. Jones’ office. Part of the follow-up that Dr. Jones wants to do after your hospital stay is for me to call you and see how you’re doing.” It’s an added benefit of working with Dr. Jones or working with the hospital. You have to sell yourself, and you have to have that little carrot.

Delivering what you promise is also important. If I say I’m going to call you in a day or two, I need to do that, to start that relationship. Or, what’s nice at the medical homes, when patients come in for their post-discharge appointment, you’re there to say hello and take part in their care. What happens is there’s two parts to transitions to care. There’s the patient you know doesn’t need to stay in, who just needs a couple phone calls or we may use some telehealth to help us. Or there’s the patient you who has heart failure, COPD, ESRD, advancing age, advancing illness — you know you need to be part of their care, so you show up at the appointment and introduce yourself as part of the care team. At that appointment, Dr. Jones introduces Joanne to the patient: “This is my case manager, Joanne, and she works with me on your care. We’re going to come up with a plan and we’re all going to work together. You’re going to hear a lot form Joanne, and she’ll be available to you when you need her.” That’s a big part of this. It’s very difficult to call and say I work for a health plan, and be as successful.”Joann Sciandra, RN, BSN, CCM, Associate Vice President, Population Health, Geisinger Health Plan

How to start recruiting patients.
  • Begin by briefly screening patients to ensure that they are an appropriate fit for the enhanced care program focused on individuals with complex needs and high costs. In the same conversation, the care team member should clearly articulate the specific services that may help the person achieve their health and life goals.
  • Provide each potential patient with something of use in the first encounter, such as information about food assistance or a community service center that could support a specific need.
  • Learn about language preferences in the target population by interviewing potential patients to learn messages that resonate with them and language to avoid. Then, develop standard practices to be sure that the care team uses language that appeals and avoids language that turns patients away. Create written materials that encompass the principles of health literacy and are tailored to individuals in the population with complex needs and high costs.

“The Camden Coalition’s relational intervening approach is the strongest approach I’ve seen, so that’s the approach we employ. We first try to reach out to individuals when we know they’re seeking help, whether they’re coming to primary care or they are admitted to the hospital or they are in the emergency department. We try to engage them as much as possible at the point of care and at high-risk times when they have the greatest needs. Once we sit down with them, we don’t hand them a brochure; we ask them, “What are your needs right now?” We have a conversation about their struggles with health, how they define health using very broad-based, open-ended questions.

Once we feel like we have started to build a rapport, the key question we ask is, “What are three things that you really want to work on in the next month to improve your health?” Then we introduce our program specifically with those three things in mind. We might say, “What is the housing issue you have? We could sign you up for Housing for Health, which will be a pathway toward permanent support housing. For the diabetes, I know one of the struggles is understanding your medications; I can help connect you with diabetic educators that might support you in that because you have identified that as an area of where you want help.” The services offered are tailored toward their specific needs or issues that will help and improve their health over the next month. That helps us really engage them at the front end.”Clemens Hong, MD, a primary care physician, and Medical Director of Community Health and Improvement for Los Angeles County, California

Meet potential patients in the hospital.
  • Some teams deploy outreach staff directly to a local emergency department or inpatient unit to meet prospective patients while their health challenges are difficult to control. This approach may be supportive for some people and overwhelming for others. It requires a relatively deep partnership with the hospital.
  • Once the partnership with the hospital is established, begin testing this method by deploying one staff member for one day every week or two. Come together as a team to explore whether the deployment resulted in appropriate referrals, and consider ways of building this capacity into the team in an ongoing way if it was effective.
Seek referrals from primary care providers.
  • When seeking enhanced care model referrals from primary care providers, be diplomatic in language choices, emphasizing the good work that physicians accomplish, the fact that some patients are not doing well despite their best efforts, and the promise of support for patients and relief for providers.
  • In meetings with primary care providers, outline the characteristics of the chosen population segment in clear terms. Review inappropriate referrals and discuss why they are inappropriate. Begin by creating simple and effective referral mechanisms to simplify the process (e.g., providing a pre-scripted letter for referring providers, or making enhanced care model staff available to attend a patient appointment to introduce the program).
“We started by calling patients and trying to reach out to them using traditional outreach via telephone. We don’t use patient portals for outreach preferring instead a person-to-person interface. What really works for us is a face-to-face introduction, also known as the warm handoff, where a provider introduces the program and makes an introduction to a care manager in vivo.”Eleni Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Health Alliance
What to do if you meet resistance.
  • Some people with complex needs and high costs will be reluctant to engage in care. The care manager or other staff member having the conversation with the patient should make sure to communicate that care is available when the person is ready, and that he or she understands they may not feel ready today.
  • Develop a strategy for future recruitment of patients who have declined care.  
Tips and guidance for using effective methods to recruit patients:
  • Take advantage of any face-to-face encounter with potential patients, connecting with these individuals about their health, sharing information on the enhanced care program, and offering something of value to the patient if possible, for example, a referral to a needed service such as a food bank or teaching them how to connect with loved ones on Facebook.
  • Review the Camden Coalition Hotspotting Curriculum, which is as an excellent resource on engaging patients, including how to recruit individuals for enhanced care.
  • At Stanford Coordinated Care, an ambulatory care ICU for Stanford employees and their families, potential patients can take a self-assessment to determine if they are a good fit.
  • If your work involves bringing patients from a different primary care practice into your care model:
    • Engage in conversations with primary care providers to help them understand the benefits of the new care design to patients and to the system as a whole.
    • Appeal to primary care providers to consider patients on their panel who have been unable to make progress so far.


“From a patient barrier perspective, the question is how do you engage someone who’s not had a lot of support in their lives, who’s had a lifetime of trauma and has had to be in survivor mode? How do you get people to really believe that they can make a change to their health status when, for so many years, they have just been trying to survive?

It is really about building new engagement models. The key lesson for us has been the more that we are able to engage with people on their own turf outside the walls of the primary care clinic, where they identify as a patient and become more passive, the more effective we are. So we do a lot of community outreach. We go to places where our members are living their lives and find that the rapport, trust, and relationship building and engagement is more successful. Often what they need is not traditional medical care. They need somebody helping to equalize the playing field, developing a really robust rapport and trust with them to help them walk through all the different health care systems they have to interact with and help make sense of it for them.” Rebecca Ramsay, BSN, MPH, Executive Director, Population Health Partnerships, CareOregon

4. Assess each patient’s experiences, strengths, and needs.

Assess the full range of needs.
Create a manageable assessment process.
  • Be sure to create a stepwise assessment process that allows the person to tell their story over time. A thorough assessment involves many questions, most of them personal and sensitive in nature. Trying to accomplish a comprehensive assessment in a first meeting, or even during a single week of interactions, is likely to be overwhelming, draining, and emotionally difficult for the person the care team hopes to serve.
  • Assessment will continue throughout the entire care journey and can be a powerful tool in eliciting patients’ motivation to engage in care and change health behaviors.
Connect prospective patients to care.
  • Sometimes, the initial assessment will reveal that the person is not a good fit for the enhanced care model. In that case, make sure to refer the prospective patient to another local service provider that can support their needs.
Tips and guidance for using effective methods to assess each patient’s experiences, strengths, and needs:
  • Conduct the initial assessment to learn about the patient’s experiences, strengths, and needs within the first 30 days of patient enrollment in the enhanced care program, based on contractual requirements.
  • Design an assessment process that allows the collection of needed information over the course of the first 30 days in a way that does not overwhelm patients.
  • Recognize that assessment will unfold over the course of the care journey; we learn more about each other as we get to know each other better, and circumstances and needs may change over time.

5. Co-create individualized care plans with each patient.

Defining co-created care plans.
  • As discussed in Developing the Care Model section, the key tool in designing enhanced care for populations with complex needs and high costs is co-creating individualized care plans. A co-created care plan is an action plan to guide care delivery for one specific individual.
  • Co-creation means that the patient works in partnership with the care manager to outline goals, interventions to support goal attainment, immediate next steps, responsibility for action items, and feedback loops around progress.
Why co-create care plans?
  • There are various reasons that co-creating a care plan directly with each patient, eliciting goals from the patient, and determining the patient’s own prioritization of those goals is crucial. Most importantly, if the care team does not focus on the patient’s own top priority, and instead directs care to manage a health condition, it is unlikely that the patient will engage in care over time. Teams in enhanced care programs have found that the best way to encourage patients to continue in care is to shape care delivery around the patient’s own top priorities.
  • Another reason the co-creation of care plans is so important is that typically, individuals with complex needs and high costs have had numerous traditional care plans in the past, and their continued high utilization and poor health outcomes demonstrates that such plans have not been effective.
    • Traditional care plans include drop-down menus of cookie-cutter goals around symptom management and treatment protocols.
Focus on patients’ own goals.
  • The co-created care plan must center on the patient’s own top priority goals. Some goals may not appear to be health-related, for example, a patient may prioritize the ability to re-establish family contact or return to a social activity.
  • Care teams that fully engage around patients’ own goals find that, with time, this approach does encompass health promotion and self-management, as the person will need to make improvements in chronic health or behavioral health conditions to engage in life as they desire. Begin by asking what is most important to the person now and what they need to work on immediately to achieve those goals.
Using the care plan to develop trust.
  • Co-creating care plans involves more than eliciting and following the prioritization of a patient’s own goals.
  • Teams that develop the care plan in a space where the patient feels comfortable, perhaps at home or in a local coffee shop, or with the input of a patient’s friend or family member at the patient’s request, deepen the trusting relationship between care manager and patient. That trusting relationship will be a boon as the patient and care manager navigate care delivery together and come together frequently to assess progress toward goals and establish new goals as needed. Start by acknowledging that every interaction offers an opportunity to develop trust.
Carry out the care plan.
  • Carrying out the care plan requires ongoing contact between the care manager and patient, sometimes weekly or more frequently. Care managers skilled in using motivational interviewing techniques are able to draw out patient goals in the face of a patient’s ambivalent or conflicting feelings.
  • Knowledge and agility in using trauma-informed care methods creates a space where patients are more likely to feel at ease, even when they have a significant trauma history; methods include forms of inquiry, body language, and easy access to exits.
  • Care plans relate to the development of self-management skills and the increase of a person’s ability to manage their situation. Such developments and improvements may also be used to assess whether the person is ready to transition out of the enhanced care model and into traditional primary care. Begin by making sure that each patient has a written copy of their care plan. 
Review the care plan at each visit.
  • The care manager will review progress toward the care plan in each meeting with the patient. Once a goal is accomplished, the care manager will work with the patient to elicit their current goal and document a new or updated care plan.
  • Similarly, the care manager consistently confers with the care team to discuss the patent’s needed level of care and support the development of self-management. 
Tips and guidance for co-creating individualized care plans:


“We worked with a man who was disabled by his Parkinson’s disease — he was introduced into the program by his wife. In the first visit, he was dragged in forcefully and fairly unwilling to come. He was sitting slumped over, leaning radically sideways, making no connection about anything and basically he felt hopeless. We identified that, before Parkinson’s, he loved being a long-distance runner. At the time of this first visit, he was about eight years into having Parkinson’s and on some medications, but life for him was over essentially — he was waiting to die, with some potential suicidality but no active plan, and not a happy guy.

We asked the question, “What stopped you from running?” He looked at us incredulously and said, “I have Parkinson’s disease and I have foot pain, and I have this and that.” We said, “Yes, we know that, so what kept you from running?” We ended up looking at his feet and realized that his shoes were too small, and the toe problem he thought was from Parkinson’s was actually a shoe problem so he got better shoes. He lived across the street from a little park, where the walk around the park was about a quarter mile. We asked him, “Do you think you could get around that park once and then tell us how it goes with a shuffle/fast walk gait?” He was able to do that. We have a physical therapist, so she also worked on his posture and things like that with him. His goal was to be able to run Bay to Breakers, a famous eight-mile race in San Francisco. A year later, by starting with going around the park once a quarter mile, he is back to running long distance; he ran the race and has continued to run three to five miles, five times a week. His entire self has changed. He’s sitting up. His eyes are bright. He’s engaged. He’s thinking about the future. His Parkinson’s has not gotten better; it’s the same, but he became activated. It was by focusing on what he cared about most, which was running, and then helping him figure out a path back to it. “Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care

6. Align one care manager as the primary support for each patient.

Individuals encountering the enhanced care model have likely interacted with countless health care professionals, which is why it is vitally important that the patient builds an ongoing relationship with one person on the care team. While the interdisciplinary care team is a key characteristic of the enhanced care model, it is crucially important that the care team identifies one person as each patient’s key support person. This role is typically fulfilled by the care manager.

Who serves as a care manager?
  • In the enhanced care model, people with various credentials may serve as care managers. When medical needs are very intensive, a nurse care manager can be a good fit, while patients with primary mental health, trauma, and substance abuse needs are well-served by social workers, behavioral health workers, and sometimes peer specialists. Some teams up-skill medical assistants to provide care management support to patients, while other teams find that community health workers are a good match.
  • As with all aspects of care redesign, aligning the right staff to the care management position will require testing. To begin, outline the array of patient needs, then try serving the first five patients with existing care management staff. Observe the interactions across the early part of the care journey, looking for signs that the fit is effective or could be improved, and take steps to refine the enhanced care model accordingly.
What is the role of the care manager?
  • In the enhanced care model, the care manager carries out the assessment process, engages the patient in co-creating a care plan, and is responsible for keeping track of whether or not the care team and the patient carry out their given responsibilities toward the proposed goals. The care manager role involves developing a long-term relationship with each patient built on trust and understanding. A core capacity is great listening skill. The care manager aligns other members of the care team to support the patient, through direct communication, electronic reminders, and care team meetings.
  • The care manager also leverages needed community supports to enrich the care plan, as decided in partnership with the patient. Community supports can be as varied as a church group, an Alcoholics Anonymous sponsor, a mental health counselor, or a dance teacher.
Tips and guidance for aligning one care manager and the primary support for each patient:
  • Given the emphasis on listening, it is imperative for care managers to have a deep ability to connect empathically with others.
  • Many teams have found that doctors and nurses are not always well-matched to the role of care manager, particularly if their focus is on dispensing information or if they struggle to listen to others.
  • Consider the cost of care when filling the care manager role. Social workers, community health workers, and sometimes peer workers are likely to be well-suited to the job tasks and are a lower-cost resource than others on the care team.

7. Build engagement skills among the care team and support the care team in carrying out effective engagement methods.

Evidence-based engagement methods are foundational to care delivery for individuals with complex needs and high costs. The ability of the enhanced care team to carry out effective engagement methods will depend upon the breadth, thoroughness, and frequency of training and supervision. One-off training experiences are not sufficient to enable staff to integrate evidence-based engagement methods into their daily work practices.

Training for enhanced care team staff.
  • Investigate local opportunities for in-person training for care team members in fostering patient self-management skills, building patient activation, motivational interviewing, and trauma-informed care.
  • Look for online training opportunities for subsequent training.
  • Consider train-the-trainer approaches to develop in-house expertise in key engagement methods, as continual training and opportunities to practice will be needed throughout the course of care delivery and as the program increases capacity in efforts to reach the entire chosen population segment.
  • Case conferences are another way to support the care team in developing an understanding of the nuances of care delivery with these evidence-based engagement methods, and to grow their confidence in carrying out the practices consistently across varied situations.
Supervision for care managers.
  • Develop a robust supervision structure to ensure that all care managers have consistent access to a colleague highly skilled in evidence-based practices related to engagement. Protected weekly or twice-monthly individual supervision sessions offer ample time for care managers to discuss nuances, raise challenges and resolve questions in delivering evidence-based engagement methods. Begin with the onboarding process of each new employee, which should include specific training in evidence-based engagement methods.
Tips and guidance for building engagement skills among the care team:
  • Prospective team members with a commitment to an authoritative, hierarchical medical model will not be a good fit for enhanced care programs for individuals with complex needs and high costs.
  • As the care team grows, careful attention is needed in the hiring process. Which values and core skills are required for prospective staff members to bring with them? Which skills can be gained through training?
  • Observe the care team to identify staff members who are particularly skilled in engaging patients. Invite these staff members to share their strategies in team meetings and perhaps as part of in-house training sessions.

8. Develop work processes to engage patients throughout the care journey.

Engage patients throughout the care journey.
  • In the course of the care journey patients will make progress, encounter crises or events that cause some backsliding, and make progress anew. Begin by communicating to the patient and among the care team that these ups and downs are an expected part of the journey and offer an opportunity for the patient to engage more in the support of the care team; develop capacity to elicit the support of reliable family, friend or community relationships; and practice self-management skills alongside the care team.
Provide supervision to support engagement and help care manager’s balance caseloads.
  • Attention to caseload management in supervision is supportive of the effort to balance caseloads. Supervisors will need to focus on managing throughput in care, ensuring that as patients are recruited into enhanced care, others who have developed sufficient self-management skills transition back to traditional primary care.
  • In supervision sessions, review staffing plans and the targets for staff caseload expectations, particularly the number of active patients and number of patients in outreach and maintenance status. Provide support and engage in problem-solving around managing the caseload, supporting the care manager to outline needed steps before returning the patient to usual care and helping the care manager elicit self-assessment from the patient.
Flexible care delivery design is needed to support engagement and changing care needs.
  • Similarly, care delivery processes must be designed to flexibly align needed levels of care to each patient throughout his or her care journey. The care manager and care team need to be attuned to each patient’s shifting level of need and modify care up or down to meet the current level of need.
  • It can be helpful for the team to create a dashboard that displays the status of each care manager’s caseload to monitor caseload fluctuation and attempt to balance caseloads, so that each team members serves a mix of patients who need higher and lower intensity support. Consider using an existing care team meeting to group patients by current level of care; even Post-It notes on a large piece of paper is a good way to start what will develop into a dashboard. And, begin shaping care delivery processes by reflecting on what worked well with the first five patients. Review an example of an Analytics Risk Dashboard from Stanford Coordinated Care.
  • Over time, the care team should work together to identify criteria to shift the care plan to meet fluctuating levels of intensity. The team will also define, as near as possible, the frequency of contact that patients in low, medium, and high levels of care require, as well as methods for reviewing and determining the level of care for each patient to reassess if more or less support is needed.
Tips and guidance for developing work processes to engage patients throughout the care journey:
  • Weekly meetings support staff in building patient’s self-management and activation, ensuring that each patient is working toward at least one goal.
  • Consistently review the care manager’s caseload in supervision meetings to flag patients who may be ready to transition to traditional primary care and identify those patients in need of more intensive support.


“From the beginning, it is important to think about how you will graduate patients from the enhanced care program. I wasn’t so aware of this need to graduate patients in the first year I was in the clinic. We have learned to say to patients, “You’re going to be with us for six or 12 months (or whatever the model might hold), and once we come to these end points together, then you know you’ll actually move back to the clinic where you used to go, or a different clinic of your choice.” There are days when I think we’re seeing four or five patients who really do have the ability to move back to primary care, but we’d set up a situation where we were so incredibly accessible, and so attentive and returned calls so quickly, that now we’ve got people who really don’t want to leave. They love our clinic. They love being able to see the same faces. We have one clerk, one medical assistant. They know everything about every patient because it’s a small enough group where you can actually keep that number in your mind. It’s a little challenging. We have to incentivize people with grocery gift cards and a graduation certificate to even get them to consider leaving.”Jeremy Long, MD, MPH, Associate Professor, Division of General Internal Medicine with the Denver Health and Hospitals, Department of Medicine

9. Foster peer-to-peer support among patients.

The value of peer-to-peer support has been demonstrated across health care and other settings and boasts a long history in mental health and substance abuse support. Peer connections are deeply meaningful and valuable in myriad ways: offering hope for one’s capacity to surmount challenges; sharing the depth of patient knowledge in navigating health challenges and the health care system; lending natural support and building interpersonal connections between people facing a common challenge.

Practically, peer-to-peer support can be accomplished in varied ways: through in-person peer support groups where people share their experiences in small discussion circle meetings and connections through social media platforms where people network around the experience of a common challenge, including opportunities for health care and other interventions.

Customize peer-to-peer support to your population and each person.
  • Learn the peer-to-peer resources in your community and connect interested patients to the resource.
  • Identify gaps in needed peer-to-peer resources and partner with internal or external organizations to create peer-to-peer resources.
  • Connect patients to online peer-to-peer support resources, including helping them reliably access the internet. An exemplar site is PatientsLikeMe.


Tips and guidance for fostering peer-to-peer support among patients:
  • Look for leadership skills among current patients to identify those who may be interested in fostering a peer support network.
  • Provide training and ongoing supervision to peer leaders, especially on boundaries and self-care.
  • Learn about any relevant insurance and funder requirements related to peer support