- What are the features of a successful primary care practice that serves patients with complex needs?
This resource provides an in-depth look at the Stanford Coordinated Care Primary Care Practice (SCC), which delivers primary care to Stanford University employees and their dependents who have complex needs. Key attributes of the practice include the following:
- Human-centered design techniques and patient input were incorporated into planning the physical space and practice processes. The practice maintains an active Patient Advisory Committee.
- SCC uses a multidisciplinary, team-based approach, aiming to meet most of the needs of its patients and thereby minimize referrals while practicing at the limit of providers’ certificate or licensure. Care is provided by phone, email, and home visits, and contact is frequent. When specialist care is needed, SCC staff members manage it, and may accompany patients on specialist visits.
- Trusting relationships are the foundation of the practice’s care model.
- Care is delivered in two phases: Focusing on patient goals and helping the patient achieve them; digging deeper using the Adverse Childhood Experiences Survey when indicated.
- Team members are trained to use quality improvement (QI) methodology and collect QI data. Training is ongoing and mostly on the job, a strategy that aims to build trust between team members. Front-line team members (the real “experts” in their own work) participate in planning improvement projects.
- Additional information about the unconventional team of doctors behind SCC can be found in Washington Monthly