Stanford Coordinated Care Reinvents the Classic Disease Management Model

The U.S. Health care system has been built on an acute care model. But what do you do with patients who are chronically ill? Who suffer from multiple serious conditions? Who see multiple specialists? And who continue to drain their own pocketbooks and resources from their health insurance pool in an unfulfilling struggle to get healthy?

Two years ago, Stanford launched an innovative program to help people with complex chronic conditions avoid costly health care emergencies, feel better and take control of their health. Today, that program—Stanford Coordinated Care—provides primary care and care support for nearly 300 patients in its clinic at the Hoover Pavilion. The team-based program is led by Stanford physicians Alan Glaseroff, MD, and Ann Lindsay, MD, and includes additional physicians, licensed clinical social workers, a physical therapist, pharmacist, care support nurses and patient care coordinators.

The brainchild of Clinical Excellence Research Director Arnold Milstein, MD, the program is nationally known as the ambulatory ICU or A-ICU. It was designed by a team of physicians, nurses, managers and systems engineers to reduce health care costs while improving people's health and experience with health care, and has been refined over the past three years in two California locations by Glaseroff and Lindsay. The A-ICU is a form of medical practice designed to exclusively serve people with major chronic illness such as diabetes, arthritis or heart problems that account for 80 percent of health care spending in the United States. When their conditions are poorly managed, these patients are likely to end up in the emergency room or the hospital, often at great cost.

The program's design reflects a fundamental truth about whether a chronic illness translates into disability—"Most patients bear some of the burden for their own health by their choices," says Glaseroff, co-director of the Stanford Coordinated Care program. Do they take their medications? Do they eat well? Do they exercise? How do they manage stress?

Because patients with chronic illness have health issues that require regular attention, the new model provides access to health coaches, teaches patients to manage their conditions through behavioral changes such as stress management, diet and exercise and supports them so they believe in their ability to succeed.

"Very often, people who come to us have been turned off by their prior experiences with health care," says Glaseroff. "They have essentially abandoned hope that things can possibly be better. We try to unlock that puzzle. When we achieve that, lack of progress turns into tremendous progress over a very short period if time."

Who benefits?

Stanford Coordinated Care (SCC) is available to Stanford active employees and adult dependents with ongoing health conditions. A typical patient has been seeing three or more specialists, is on five or more chronic medications and has been to the emergency room and/or experienced an unplanned hospitalization. The program has two levels of care: Primary Care Plus or Care Support. Patients can choose SCC as their primary care provider, or if they are happy with their primary care physician but need additional help to manage a chronic health issue, they can enroll in the Care Support program.

"Care Support is like health coaching," says Lindsay, co-director of SCC. "We have a clinical nurse specialist and a licensed clinical social worker who meet with patients and talk with them about their health goals and obstacles, and help them get more things working for them and less things working against them."

Every patient who comes to Stanford Coordinated Care is assigned a patient care coordinator who is with them during their visit, who helps them follow up on their action plans and referrals and who answers their calls and emails for routine care. This built-in patient support system helps broaden the attention and guidance patients receive, and also frees up physicians to handle more complex patient care.

"It's easy to get diagnosed with diabetes," says Lindsay. "But it's really hard to live with it." We are turning the classic disease management model on its head, adds Glaseroff. "Our whole model is based on people setting their own goals, developing an action plan and then doing everything in our power to help them achieve their goals. Success breeds more success."

Patients also receive personalized follow-up care when they're admitted to the hospital. An SCC clinical nurse specialist goes to their hospital room and helps them with the transition to home. "It's a very rich benefit of service," says Lindsay.

Proven model

In Humboldt County where Glaseroff and Lindsay successfully implemented the model with 600 patients, a Blue Cross analysis found that average total monthly health spending dropped by 16 percent over the first year. Early results from Stanford's SCC are tracking in a similar direction. For the first 27 patients enrolled at Stanford, emergency room visits and hospital admissions both declined, while patient and physician satisfaction earned perfect marks. Average monthly total health care spending declined by 39 percent, compared to the previous six months when the patients were treated elsewhere.

But because even just a few expensive, unavoidable health crises can drown out the effect of the A-ICU, all agree that the number of patients treated by the SCC program is still too small to permit a valid assessment of its impact on health. "We will need to gather data for several thousand patients from diverse pilot test sites to determine the amount of net savings typically achieved by the A-ICU," says Milstein. 

And that is exactly what is occurring now. Based on favorable results from the earliest A-ICU tests in Seattle and Atlantic City, the Pacific Business Group on Health received a $19 million grant from Medicare to expand the model in five western states. Glaseroff and Lindsay are faculty and advisors to that rollout, which expects to enroll 27,000 patients and 20 medical groups in the next three years. They have also been tapped as clinical lead faculty for the Institute for Health Care Improvement's national collaborative for complex patients, called "Better Health. Lower Cost."

"We intend to make Stanford as preeminent in the discovery of better methods of care delivery as it is in the discovery of biomedical breakthroughs," says Milstein. "Such pre-eminence will also protect the fiscal health of Stanford University Medical Center and its medical staff. Rapidly unfolding major health policy changes will strongly reward health care providers that launch and perfect innovative patient care models that make health care more affordable by improving health."

By Grace Hammerstrom