Intensive Outpatient Care Program Toolkit

Technical Assistance Tool
December 2016

This resource describes how to develop and implement a model called the Intensive Outpatient Care Program, which uses a multidisciplinary team-based approach to address medical, behavioral, and social needs of patients.

  • The staff position of care coordinator is crucial to success. Each care coordinator works one-on-one with a dedicated caseload of older adults.
  • Care coordinators can be from a variety of clinical and even non-clinical backgrounds, and they require initial and ongoing training and support.
  • The elements of a successful care model include a shared action plan; regular communication between care coordinators and participants; around-the-clock access for participants to their care team; and warm handoffs from the care coordinator to non-medical resources such as home health services, transportation services, and behavioral health care.
  • A person-centered care team focuses on the participant’s own goals for health and well-being, producing a strong partnership and shared goals between the participant and care team.
Posted to The Playbook on
Population Addressed
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
  • How should a health care organization develop and embed a care management program in primary care to improve care and reduce costs for high-need older adults?
  • What variables factor into making the program financially sustainable?
  • What tools and resources can support the day-to-day work of a care coordinator managing high-need older adults?
Level of Evidence
What does this mean?