Headline

Case study of interdisciplinary primary care program for high-risk patients based at an academic health system offers lessons on program design and implementation.

Context

Many health systems have developed intensive primary care programs for adults with high rates of past health care utilization with the goals of improving outcomes and costs by creating a specialized primary care home. This case study details how a large academic health system in the greater Milwaukee area implemented the Enhanced Care Program that included two parallel programs: a complex care management program within a general internal medicine clinic (known as the wrap program) and a primary care medical home for high-risk patients (primary care program).

Findings

The case study details the multi-component risk score used for patient identification, staffing responsibilities, patient recruitment strategies, and patient care components. Patients participating in the Enhanced Care Program reported high satisfaction, and the community health worker role was critical to support patients with complex needs. Some of the operational challenges included: a lack of staff capacity to provide counseling for psychiatric needs; legal barriers to using text messaging to communicate with patients; limited ability to bill for hospital consults by primary care physicians; and ensuring staff back-up given the small size of the program.

Takeaways

Health systems can apply the lessons of this case study when developing an intensive interdisciplinary care program designed to reduce high rates of utilization. Leaders will need to refine their program approach based on patient needs, such as by embedding these programs within dialysis units and by increasing psychology and psychiatry resources.