Care coordinators work with high-needs patients in medical practices


A three-year pilot program that placed care coordinators in medical practices helped doctors care for high-needs patients and reduced health expenses, according to Medical Economics.

Given its success, there are plans to expand the Intensive Outpatient Care Program (IOCP), which embeds care coordinators in medical practices.

Created out of Stanford University, IOCP recently concluded a demonstration pilot funded by the Center for Medicare & Medicaid Innovation that involved 23 physician practices, 500 physicians and 15,000 patients.

The model reduces health expenditures by placing care coordinators in practices to work with high-needs patients and also promotes patient empowerment by addressing the reasons why those patients have not been doing well, said Alan Glaseroff, M.D., a family physician at Stanford Coordinated Care Clinic and clinical professor of medicine at Stanford University, who helped create the program.

The care coordinator services are paid for by an independent physician association (IPA) or medical group, or integrated delivery system. One care coordinator might work with 10 practices or 20 clinicians, said Diane Stewart, MBA, senior director of the California Quality Collaborative. The medical group or IPA hires, trains, and supports the staff and works with providers to identify patients who can benefit from the program.

At Stanford University, where patients are assigned a care coordinator, emergency room visits declined 59 percent and admissions declined 29 percent.

The Centers for Medicare & Medicaid Services is putting more emphasis on primary care in the 2017 physician fee schedule. Physician practices are transitioning to value-based reimbursement systems and enhancing patient care with teams that coordinate care.

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