Breakthroughs in the affordability of clinical excellence

Husband-and-wife team Alan Glaseroff, MD (left), and Ann Lindsay, MD (middle), lead the Stanford Coordinated Care Clinic aimed at better managing chronic conditions and reducing costs. Based on the A-ICU care model designed by Dr. Arnold Milstein, the Stanford clinic currently serves Stanford employees and their family members, and will soon expand its services to other high-risk patients.

Watch a video on the Stanford Coordinated Care Clinic.

What are high-value care methods? In the 1950s, an imaginative Baltimore physician named Peter Safar realized that outcomes might improve if hospitals consolidated the location of their sickest patients and used a dedicated clinical team to increase the frequency of patient observation and treatment adjustments. His intensive care unit or “ICU” model spread to many aspects of hospital care. Hospital mortality and costly complications for the sickest patients plunged. Successful variations on his innovative care method theme include neonatal ICUs, burn units, and surgical ICUs.

The concept of redesigning care delivery methods to better meet the needs of distinct patient groups has inspired other health care improvements, though much more slowly than emerging science and technology would allow.

A freshly tested new care model: the ambulatory care ICU. People living at home with unstable chronic conditions – such as diabetes, depression, asthma, heart disease, hypertension, and those taking five or more prescription medications – often find themselves bouncing between specialists, who typically lack a full picture of their patients’ health needs, too often leading to preventable visits to emergency rooms.

As an influential national leader in clinical care innovation, a national team led by Dr. Milstein originated the concept of the “ambulatory care intensive care unit,” or A-ICU, designed to provide intensified support to such patients in order to prevent dangerous health crises and services offering no likely health gain. This innovative care method or “model” provides a locus of care coordination where patients also receive training in self-management skills, close monitoring of their medical regimens, and an unrushed opportunity to clarify their health goals with an accountable team of physicians, nurses, nutritionists, behavioral coaches, and physical therapists.

The model was first tested by Dr. Milstein among medically fragile Boeing employees in Seattle and hotel employees in Atlantic City, resulting in improved workers’ health and satisfaction with their health care, an 18-20 percent estimated reduction in annual total per person health care spending and a 56 percent reduction in employee sick days. The A-ICU model is now spreading through eight states, including Stanford’s Coordinated Care Clinic. Medicare recently awarded $19 million to scale the A-ICU innovation, both to improve care and relieve pressure on federal and state budgets. In addition, both the Veterans Administration and Kaiser are planning to implement variants of the A-ICU model.


Our first wave of care innovation design targets

The first class of CERC research fellows and faculty mentors entered in August of 2011. They targeted better care models for chronic kidney disease, colon cancer risk, poor prognosis cancer, and severe obesity. Implementation planning is underway by medical leaders, providers, insurers, and policy makers in multiple states. Within 12 months, they will be up and running in over eight pilot testing sites.

Chronic Kidney Disease: Only 1 percent of patients with chronic kidney disease will require dialysis, yet many receive this costly and often disabling treatment well before it is needed. CERC’s model of care slows deterioration of kidney function and connects patients with the least debilitating and least costly forms of renal replacement if replacement becomes necessary.

Colon Cancer Screening: CERC’s screening model increases the total percentage of people appropriately screened for colorectal cancer by using a combined low-cost immunochemical test and best-practice colonoscopy screening program.

Poor Prognosis Cancer: Half a million people are diagnosed with incurable cancer each year. Too many current treatments lead to avoidable pain and suffering, and unwanted interventions that inadvertently shorten life. CERC’s redesign of advanced cancer care places the patient at the center, assuring physician respect for well-informed patients’ preferences, immediate relief from pain and nausea, and chemotherapy at home whenever safe.

Severe Obesity: CERC’s new model reduces co-morbidities that block obesity treatment benefit and provides patients preference-tailored three-year behavior change methods. Integral to the model is a 1:1 tele-mediated relationship with a behavioral coach to sustain weight loss.

The second class of CERC fellows tackled two new national health system weaknesses: patients at high risk for stroke and adolescents in transition to adulthood with a severe chronic illness. A new class is targeting the affordability of surgical excellence.