Building an intensive primary care practice Provide better care for patients who need it most

Comprehensively address the goals and medical needs of patients with multiple chronic conditions whose needs cannot be met in a short primary care visit

$$$$$ = A small percentage of patients account for a large percentage of health care costs in a given year.

Eight steps to implementing intensive primary care in your practice 1 Identify the target patient population 2 Assess the target patient population 3 Compose the appropriate care team 4 Appropriately engage patients

Eight steps to implementing intensive primary care in your practice 5 Design the patient-centered care model 6 Build the team 7 Implement the new model 8 Track outcomes

How is it working at other practices? Palo Alto, CA Steps in Practice Summary = Stanford Coordinated Care in Palo Alto, CA Primary care clinic for Stanford employees and dependents on the self-insured health plan who are at high risk for poor (and expensive) outcomes Co-directors designed a fully capitated care model based on extensive interviews with 34 Stanford employees with chronic health conditions, in which they shared what worked for them and what they found challenging in achieving the best health possible Physician panels are limited to 300 panels; MA care coordinators have 100 patients per panel SCC model of care Huddle each morning to review the day’s schedule for potential snags, plan for procedures and review timing of slots reserved for acute visits (handled by both care coordinator and physician) PCP, care coordinator work together to complete intake, as well as to understand specific challenges that patient is facing Care coordinator checks patient understanding, reviews action plans, etc. Care is focused first and foremost on addressing patients’ self-identified goals Team is built for success Weekly clinical and operations meetings are held for all team members Teams help to decide who should become involved in each patient’s care going forward Model is capitated for services it provides Paid by the month, which protects the longer-visit model Everything is sent through the secure patient portal online SCC uses dashboards that draw from their HER Care gaps dashboard about routine tests and immunizations that are due Risk dashboard identifies patients who are high risk for poor and expensive outcomes

For additional resources, frequently asked questions and implementation support, visit www.stepsforward.org!