Why patient engagement matters: Coordinated care at Stanford

Aug. 1, 2018 / By L. Gordon Moore, MD

Dr. Alan Glaseroff developed Type I diabetes as an adult.  As a family medicine physician, he was surprised by the work involved in really understanding the condition and the best ways to manage it to optimize outcomes. He was also surprised by the gaps in support and began a journey with his patients to figure it all out.

I had the opportunity to speak with him recently for the Inside Angle podcast. He described the confluence of his personal journey and the emerging work in healthcare delivery around effective support for people with chronic conditions. With the Chronic Care Model came a strong evidence base for working with people and supporting them in their own journeys to better health. 

The Institute for Healthcare Improvement combined process improvement, subject matter expertise and learning theory in support of healthcare delivery change.  Dr. Tom Bodenheimer and colleagues at UCSF’s Center for Excellence in Primary Care developed a model for multi-disciplinary team-based care to broaden the scope of services and supports for people in primary care settings.

Dr. Alan Glasseroff and his spouse Dr. Ann Lindsay designed and implemented a new comprehensive model for patients with complex needs at Stanford University in 2011. 

The Stanford Coordinated Care (SCC) model is a service for patients (employees and their dependents) with complex chronic conditions at high risk for medical resource utilization.  The model aims to reduce unnecessary medical resource utilization through improved care delivery.

Their use of human-oriented design informed their work on improving relationships with their patients, focusing on patient-defined goals and measures of patient activation, and used close follow-up as techniques to improve outcomes.  Their work led to an AHRQ case study and advisory roles to the NCQA in development of the Patient-Centered Medical Home recognition program.

Listen to Dr. Glaseroff describe design elements of improving chronic care delivery on the Inside Angle podcast and use these principles as you design and modify your programs.  Your patients with thank you and your outcomes will improve, and Dr. Glaseroff says this works in fee-for-service as well as capitated payment models.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.