stanford medicine


Heal simple - How to coordinate

in Brief

Heal Simple

How to coordinate
complex care

Ann Lindsay and Alan Glaseroff run Stanford's clinic for people with multiple chronic health conditions — a clinic they hope will influence others.

A new and relatively small clinic at Stanford Hospital & Clinics could play an outsized role in influencing care for chronically ill patients.

The Stanford Coordinated Care Clinic opened in the spring to university and medical center employees who struggle with one or more complex, chronic conditions. It aims to help such patients lead healthy lives and get regular medical support.

For people with multiple chronic conditions, getting good overall care is often complicated by insufficient, or non-existent, communication among their many doctors. The result is a lack of agreed-upon goals for health improvement, little or no coordination of care and no accountability.

Not only is this bad for patients’ overall health, it’s also bad for their pocketbooks and their insurers’ bottom lines. When no one closely monitors and manages such patients – or properly educates them about how to deal with their diseases – they tend to land more frequently in emergency rooms and intensive care units, racking up lots of hospital bills. More than 75 percent of health-care costs are due to chronic conditions, according to the U.S. Centers for Disease Control and Prevention.

The new clinic, directed by the husband-and-wife team of Alan Glaseroff, MD, and Ann Lindsay, MD, serves as a home base for such patients – a kind of health-care command central – where they can turn for 24/7 help. Its clinicians will even visit patients at home. The staff, which includes a nurse, a social worker, a physical therapist and patient-care coordinators, monitors patients’ medical regimens and progress toward health goals; coordinates with specialists to make sure they understand the patients’ needs and preferences; and gives patients the tools and knowledge to manage their diseases.

“Patients are the most important determinant of their own health outcomes,” Glaseroff says. “Their own behavior is at least four times as important as the care they receive. It makes sense to make them a member of the care team rather than an object of its services.”

Providing aggressive primary care to the sickest patients to reduce their use of hospital services has been done before elsewhere. But these efforts have focused on specific populations, such as a single company’s workers or a city’s most vulnerable residents. Glaseroff and Lindsay want to figure out how to replicate this kind of care across a broader demographic.

They will report what they learn from running the clinic to the Pacific Business Group on Health, a coalition of 50 large businesses that is leading a $19.1 million program to improve care coordination for 30,000 Medicare and dual-eligible Medicare-Medicaid beneficiaries in California and Arizona with multiple chronic conditions. The program is funded by the Center for Medicare & Medicaid Innovation.

The couple also will report on their experience with Priority Care, a similar program led by Glaseroff in Humboldt County.

“We’re trying to develop a framework that could be used anywhere,” Glaseroff says.

At present, the clinic cares for about 65 patients, and that number is growing. It plans to expand its services to non-Stanford employees in the future.

“It can be hard to face a chronic condition alone,” Lindsay says. “We will help patients take control of their life and health.”







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