Lessons from the Field

diane-craig-mdKaiser Permanente Santa Clara Medical Center
is a general medical and surgical hospital in Santa Clara, CA.

“We have a lot of people doing pieces of this work already. Rather than simply adding on a new service with new people, we started by identifying existing internal resources already serving our patients with complex needs and high costs. For example, we have a program for MediCal patients with dedicated resources, including physician time. One goal for patients in our enhanced care program is a team-based approach and breaking down the siloes that we have in our existing programs. Our patients with complex needs and high costs come from our hospital; we’ve got people that are involved in the complex chronic conditions program, primary care, and psychiatry. We are trying to provide more global care for these patients rather than having them in individual programs.

We want to figure out how to leverage our colleagues who are already supporting these existing programs and their skills. To get started we pulled together people who represent all those different sites of care, which sometimes can be siloed even though we’re one organization, and try to figure out what’s currently in place. Our goal was to evaluate the enhanced care model against these different existing programs, with input from people who understand these programs:

  • What are the gaps?
  • Where is the overlap?
  • What are the things that we’re not currently providing well?
  • What can we learn from others within and outside of our organization?
  • How might we reorganize what we’re doing to better meet the needs of this subset of our population rather than build an enhanced care program from scratch?

Now, there’s an increased awareness about the need to integrate, coordinate, and avoid duplication and fill gaps. We’ve gotten started on the process of coordinating across those programs.” Diane E. Craig, M.D., F.A.C.P, Assistant Physician-in-Chief, The Permanente Medical Group, Santa Clara Medical Center

joannGeisinger Health Plan is a not-for-profit health maintenance organization (HMO) serving forty-three counties in northeastern and central Pennsylvania.

“As in most organizations, internal partnerships are a struggle. For our enhanced care programming, we initiated conversations, starting with regional medical directors, about goals for the enhanced care model and got their input. We started our work with heart failure and COPD; we brought in a primary care provider and a cardiologist.  Through these conversations, we learned who they are and started identifying the qualities for the right person to do this work.

Another big thing we did in the beginning  in our medical home meetings, I’d go with the regional medical director to the medical home meeting and talk about cases. We were careful in our approach as some providers are open-minded about changes and some aren’t. In some clinics we could jump right into discussions and offer new ways of thinking, for example, asking: “Did we ever think about giving the patient a protocol if they gain weight? How can we do that? Asking if we have the right services for the right patient?” For providers who didn’t seem ready to engage, we would try to start that conversation and try to plant a seed. So, it’s about a partnership. If we go in and say, ‘we’re going to do this,’we’re never going to succeed.”

Joann Sciandra, RN, BSN, CCM, Associate Vice President, Population Health, Geisinger Health Plan

metge-photoThe Winnipeg Regional Health Authority
in Winnipeg, Canada describes their strategy for partnering.

“We operate on a matrix structure, which means we have programs like Medicine, and Surgery, and Women’s Health that cut across different hospitals and community sites. If you do not work the matrix, where the enhanced care program and the sites intersect, then it is very difficult to partner appropriately.

The most successful strategy for partnering is based on first understanding the patient’s needs, and then finding the services that will meet those needs. That is the beginning of building things together with partners. It also helps to have a leader who can reach out to people. It takes purposeful hand-shaking: identifying key stakeholders and building relationships.

Partnerships with a variety of resources allow us to more easily meet the needs of individuals. Once we understand the needs of the person in question, then there is intensive case management with interdisciplinary team-based care, care coordination, and communication with existing partners. We create a visual around patients’ needs, services required, and partners required. Then patients are transitioned to appropriate community resources, which may include primary care upon achievement of goals. People are meant to leave our service — that is a core element of our enhanced care model and the partners we have to line up based on patient need.” Colleen Metge, MD, Director, CHI Evaluation Platform Division Quality & System Performance, Winnipeg Regional Health Authority

allurelogovnsnyVisiting Nurse Service of New York (VNSNY) is a not-for-profit home- and community-based healthcare and hospice organization in the greater New York metropolitan area and The Allure Group, a group of Brooklyn-based skilled nursing facilities and rehabilitation centers. The following is a description of the lessons learned from VNSNY and their partner.

“We decided to focus on end-of-life care and that VNSNY needed to build this partnership with Allure and create the culture and environment to provide hospice services inside the nursing home. To bring about this change, we saw the need for the dedicated joint collaborative project to focus on our patients with complex needs and high costs. It has been a process.


To create an effective partnership we did a number of things. We always start with the three Cs: communication, coordination, and collaboration. We reinforce this over and over, and we think that’s really the hallmark of this project. We established a culture of bringing every issue to the table so that each group should feel comfortable that we’re not finger-pointing, that we’re really focusing on lessons to learn and share and spread. We developed this culture of openness and driving improvement and change. It’s almost like a competition, who can identify something that we can improve, and not be afraid to bring it to the table? We have ongoing communication. We’re on phone calls together, we talk together, we communicate via email, we meet face to face — we have developed a culture of openness and transparency working together to benefit a highly complex patient population that we jointly serve. Now that we have a strong foundation for working together we not only strategize and brainstorm around end of life, but identify opportunities for other clinical partnerships.” Adina Kolatch, Consultant, Visiting Nurse Service of New York