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?
What does it take to deliver patient-driven care?
Strategies to build trust.
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
Patient activation
Motivational interviewing
Trauma-informed care
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.
Deploying staff to recruit patients.
How to start recruiting patients.
Meet potential patients in the hospital.
Seek referrals from primary care providers.
What to do if you meet resistance.
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.
Connect prospective patients to care.
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.
Why co-create care plans?
Focus on patients’ own goals.
Using the care plan to develop trust.
Carry out the care plan.
Review the care plan at each visit.
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?
What is the role of the care manager?
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.
Supervision for care managers.
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.
Provide supervision to support engagement and help care manager’s balance caseloads.
Flexible care delivery design is needed to support engagement and changing care needs.
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.
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