This HealthAffairs article looks at how to use an intensive outpatient care program to lower the cost of caring for high-cost patients while improving their care.
The model is driven by workforce training and has seven key elements, say the authors:
- “Trained Care Coordinators such as nurse or social worker-led teams that can include community health workers and medical assistants.
- “A face-to-face super-visit within one month of enrollment.
- “Standardized longitudinal assessment tools for physical function, mental well-being and patient engagement in care.
- “Monthly, bi-directional communication between the care coordinator and patient;
- “Shared Action Plan created with the patient’s own goals at its center.
- “Warm handoffs to relevant support services such as home health, behavioral health, and transportation.
- “24/7 access to services, with communication to the care coordinator the next business day.”
