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Service Delivery Innovation Profile

Primary Care Physician and Health Coach Teams Improve Outcomes and Reduce Costs for Complex Patients

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A primary care practice known as the Special Care Center receives a flat monthly fee per patient from payers such as a local union trust to deliver intensive primary care management services to high-cost, medically complex members with chronic conditions. A physician-health coach team works with these patients to develop a customized care plan, with the plan being reviewed and revised as needed. Each patient receives a variety of ongoing care and care management support as dictated by the care plan, including regular phone and e-mail communications from the health coach, hospital and home visits, group visits, and other support. Regular communication across providers and a patient registry support the effort. The program improved self-management behaviors and clinical outcomes, leading to lower utilization, a significant slowing in the annual rate of cost increases, and markedly higher levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key measures of clinical outcomes (including blood pressure, LDL cholesterol levels, and blood glucose levels), utilization (including inpatient days, length of stay, admissions, readmissions, and ED visits), cost increases, and patient satisfaction, along with post-implementation data on smoking quit rates and medication compliance, with comparisons to community averages where available.
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Developing Organizations

AtlantiCare; Hotel Employees and Restaurant Employees International Union Welfare Fund; Renaissance Health
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Use By Other Organizations

The A-ICU model, on which the Special Care Center is based, has been used by a small number of other progressive payers and providers in the United States. The Boeing company sponsored a pilot for its sickest patients with three large medical groups in the Puget Sound, WA area; this also showed improved outcomes and lowered net health care costs.5 The Union Health Center in New York, NY also has implemented this model with a union population.6

Date First Implemented

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Patient Population

Vulnerable Populations > Medically or socially complexend pp

Problem Addressed

Individuals with one or more chronic illnesses represent a large and costly population. Most physician groups have limited capacity and incentive to meet the complex needs of these patients.
  • A large and costly population: Approximately 133 million Americans—nearly 1 of every 2 adults—have at least one chronic illness; each year, 7 out of 10 deaths among Americans are due to chronic illness.1 The annual cost of treating someone with a chronic illness can be nearly $40,000 higher than for someone without a chronic condition.2 Treating patients with several chronic conditions can cost as much as seven times more than treating patients with only one chronic illness.3 Individuals with chronic conditions account for more than 80 percent of all health care spending, with such spending expected to increase substantially over the next 20 years.4
  • Limited capacity and incentive for medical groups: The culture, structure, and financial incentives of most medical groups limit their ability to meet the complex needs of chronically ill patients. Consequently, most medical groups focus on treating acute conditions and have little or no ability to provide the ongoing, intensive care management required to manage chronic conditions effectively. Furthermore, under fee-for-service (FFS) reimbursement mechanisms, medical groups do not receive compensation for activities—such as health coaching and phone and/or email communications with patients—that can improve outcomes and reduce costs for those with multiple chronic conditions.

What They Did

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Description of the Innovative Activity

A primary care practice known as the Special Care Center provides intensive care management services to high-cost, medically complex patients with chronic conditions such as diabetes, hypertension, asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and congestive heart failure (CHF). A physician-health coach team works with the patient to develop a customized care plan, with the plan being reviewed and revised as needed. The patient receives a variety of ongoing care and care management support as dictated by the care plan, including regular phone and e-mail communications from the health coach, hospital and home visits, group visits, and other support. Regular communication and a patient registry support the effort. Key elements of the program include the following:
  • Identification of medically complex patients: Patients eligible for the program originally came from the Hotel Employees and Restaurant Employees International Union Welfare Fund (see the Context section for more information) and employees of the sponsoring health system, AtlantiCare. Using a predictive computer model, program leaders identify and invite the most costly patients (defined as the top 10 percent in terms of expected total health care expenses) to join the practice. Hospital case managers may also make referrals to the practice, whereas patients with multiple chronic illnesses may self-refer. All referred patients must complete an application that collects information similar to that used by the predictive model (e.g., number of medications, list of conditions, number of emergency department or ED visits in the past year) to confirm eligibility for the program. As of the summer of 2010, the program serves approximately 1,200 union members with one or more chronic illnesses, including hypertension (74 percent), diabetes (56 percent), asthma (18 percent), COPD (18 percent), and CAD (12 percent). 
  • Team-based care from physician and culturally matched health advisor: Each patient receives care and care management services from a "teamlet" that includes a physician and personal health coach (either a nurse or community health worker). The physician provides necessary medical care, whereas health coaches educate patients about their chronic illnesses and appropriate self-management activities, including physical activity, nutrition, medication use, management of blood pressure and blood sugar, stress reduction, and other issues. Health coaches are culturally matched with patients; they often come from the same community and frequently have similar chronic conditions (or family members with such conditions).
  • Creating and maintaining an individualized care plan: The patient, physician, and health coach meet initially to review the patient's health status, mutually agree to health-related goals, and create a care plan designed to achieve those goals, including recommended frequency of visits and desired self-management steps. For some patients, the plan calls for an in-person visit every few months, whereas for others the plan calls for more frequent visits and/or contact via the phone or e-mail, with some patients being contacted every day. The health coach and physician review the health status of all patients on an ongoing basis to determine his or her needs and revise the care plan as needed.
  • Ongoing engagement and support of patient as needed: The teamlet supports the patient as necessary in any of a variety of ways, as outlined below:
    • Regular followup from health coach: On an ongoing basis, most patients receive regular phone calls and/or e-mails from the health coach, who takes the lead on most interactions with the patient. During these communications, they remind patients about followup and self-care needs, answer questions, and address patient concerns related to health status.
    • Home or hospital visits: As needed, the physician and health coach may visit the patient at home or in the hospital if necessary.
    • Group visits: The practice holds group visits that bring together patients with the same disease (e.g., diabetes, CHF) or same needs (e.g., to lose weight, engage in physical activity such as walking). During these sessions, patients share experiences and self-management strategies; an individual may participate in multiple groups depending on their needs and interests.   
    • Onsite ancillary services: The center offers a variety of onsite services that the team can access as necessary for a patient, including a pharmacy; laboratory and radiology services; and a part-time psychologist, social worker, and nutritionist.
    • As-needed specialist referrals: Patients can be referred by the physician and/or health coach to offsite specialists for services as needed. 
  • Seamless communication across relevant providers: The Special Care Center uses several formal mechanisms to facilitate communication across the team and with relevant offsite providers, including daily and weekly meetings, an open office design, and regular interactions with the hospital and specialists, as outlined below: 
    • Daily team "huddles": All providers meet each morning for 45 minutes. During these sessions, the team identifies and plans subsequent care steps for any patient who has visited the ED and/or been admitted to the hospital in the last 24 hours (the hospital notifies the center about such patients); identifies and determines needed interventions for any patient who seems particularly ill; and reviews patients scheduled to be seen that day to determine any needed changes to his or her care plan. 
    • Weekly practice improvement meeting: The practice holds a 1-hour weekly team meeting to design and review practice improvement initiatives.
    • Open office design: The office has a large open area where physicians, nurses, and health advisors have their desks; this arrangement encourages ongoing, informal communication about patient needs.
    • Regular communication with hospital and specialists: Center staff regularly communicate with hospitalists, hospital-based case managers, and specialists to ensure seamless care.
  • Patient registry to ensure receipt of needed care: The practice uses a Web-based patient registry to facilitate appropriate disease management; the registry lists each patient and produces a visit planner with a disease-specific checklist of needed services (based on clinical guidelines). The health coach uses this list to identify and address any gaps in care on an ongoing basis, whereas the practice uses it for population health management—to identify areas where it systematically fails to provide needed care to groups of patients. The practice also uses an electronic medical record (EMR) for all documentation, with all examination rooms and work areas having desktop computers and each clinician and health advisor using a tablet computer that links to a secure wireless network. However, as discussed further in the Adoption Considerations section, the EMR has not proven to be critical to effective chronic disease management.

Context of the Innovation

AtlantiCare, a large not-for-profit health system and the largest non-casino employer in southeastern New Jersey, operates the AtlantiCare Regional Medical Center (a 567-bed teaching hospital with campuses in Atlantic City and Pomona), AtlantiCare Health Services, AtlantiCare Behavioral Health, and the AtlantiCare Foundation. The Hotel Employees and Restaurant Employees International Union Welfare Fund is a large multi-employee Taft Hartley Trust that provides health care benefits to approximately 25,000 largely low-wage hotel and casino employees and their families. The Special Care Center is based on a care model called the Ambulatory Intensive Care Unit (A-ICU), which was funded by the California HealthCare Foundation, led by Mercer, and shaped by a multiple-disciplinary team of creative leaders from Renaissance Health, UCSF Family Medicine at San Francisco General Hospital, Directed Creativity, and Patient Infosystems. Faced with escalating care costs, particularly for employees with multiple chronic conditions, AtlantiCare and the Welfare Fund, with consulting support from Mercer and the Union Health Center, adopted this model with the aim of improving outcomes and reducing costs by actively managing medically complex patients according to their individual needs. Renaissance Health, a health care innovation company based in Cambridge, MA, was contracted to lead the buildout, and later to operate the special Care Center on an interim basis. Although the Special Care Center originally served only participants of the Local 54 Fund and AtlantiCare employees, it has subsequently been opened up to other patient populations.

Did It Work?

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The program improved self-management behaviors and clinical outcomes with markedly higher levels of patient satisfaction. Various measures of service utilization and total cost rose and fell over time. Preliminary, not yet statistically significant measures of total per capita health spending versus a concurrent control group suggest that the center generated net savings for the Fund for those patients who entered the Special Care Center after its first year of growing pains.
  • Better self-management: The program has improved self-management behaviors related to smoking and medication compliance, as outlined below:
    • Many smokers quitting: Nearly one-half (48 percent) of all smokers quit after 6 months in the program, while nearly two-thirds (63 percent) of smokers with CAD quit over this time period.
    • High medication compliance: Prescription fill rates have averaged roughly 98 percent among program participants, well above the community-wide average of between 70 and 80 percent.
  • Improved clinical outcomes: Patients enrolled in the program for at least 6 months experienced significant improvements in clinical outcomes related to hypertension, cholesterol, and blood glucose management, as outlined below: 
    • Better control of hypertension: The percent of patients with hypertension in good control (defined as systolic blood pressure or SBP of less than 140 mm Hg) increased from 68.4 percent at enrollment to 82.3 percent after 6 months. The percent with poor control (an SBP greater than 160 mm Hg) fell from 8.5 to 2.4 percent over the same time period, with an average drop of 26 points in this group. The percentage of diabetes patients with SBP greater than 140 mm Hg fell from 26.1 to 15 percent.
    • Lower cholesterol levels: Patients who entered the practice with a low density lipoprotein (LDL) level of 130 mg/dL or above experienced an average decline of 30 points after 6 months in the center, while those who entered with an LDL above 160 mg/dL experienced an average drop of 50 points. The percentage of patients with low cholesterol (defined as LDL less than 100 mg/dL) increased from 69.9 percent to 77.1 percent. The percentage of diabetes patients with poorly controlled cholesterol fell from 15.8 to 11.4 percent.
    • Better blood glucose control: The proportion of diabetes patients with poor blood sugar control (defined as a hemoglobin A1c greater than 9 percent) dropped from 20.2 to 11.9 percent after 6 months in the program, with an average drop of 2.38 percentage points in this group. The proportion with excellent control (hemoglobin 1c less than 7 percent) rose from 40.8 to 52.5 percent.  
  • Less steep cost increases, lower utilization: Total health care spending among program participants rose by only 4 percent in the year after enrollment, well below both the 31 percent increase for this same group of individuals in the year before enrollment and the 12 percent average increase for the Local 54 Fund's Atlantic City population as a whole. The center's patients exhibited significant declines in inpatient days (29.6 percent), length of stay (8.1 percent), admissions (23.9 percent), readmissions within 30 days of discharge (roughly 80 percent), and ED visits (22.4 percent) after enrollment. Another source of cost savings came from increased use of generic drugs, as generic prescribing rates jumped from 43.4 percent in the third quarter of 2007 (roughly in line with the community average) to 64.5 percent in the first quarter of 2010.
  • Higher patient satisfaction: Survey data show marked increases in satisfaction among those enrolled in the program (as compared to their experiences before), with gains of 30 to 40 percentage points on questions related to access and timeliness of care, respect for the patient, time spent with the provider, communication, and coordination of care between the primary care team and specialists.
  • Trend toward lower utilization: A case-control analysis of all 447 patients enrolled in 2009 showed that, relative to controls, patients in the center had higher (40 percent) prescription fills, slightly fewer physician visits (4 percent lower) but much lower outpatient procedures (23 percent lower), inpatient admissions (41 percent lower), and ED visits (48 percent lower). Monthly costs per enrollee relative to the control group were $52 higher for physician visits, $73 higher for drugs, $2 lower for outpatient procedures, $29 less for ED visits, and $351 lower for inpatient care. Overall net spending relative to controls was $208 per enrollee per month lower than controls, which represented 12.3 percent of total spending.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key measures of clinical outcomes (including blood pressure, LDL cholesterol levels, and blood glucose levels), utilization (including inpatient days, length of stay, admissions, readmissions, and ED visits), cost increases, and patient satisfaction, along with post-implementation data on smoking quit rates and medication compliance, with comparisons to community averages where available.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Identifying and building practice site: Program leaders decided to construct the Special Care Center in an AtlantiCare-owned medical building located near the casinos.
  • Hiring staff and creating practitioner relationships: AtlantiCare and Renaissance Health representatives interviewed and hired physicians, health coaches, and other staff; arranged part-time coverage from a nutritionist, social worker, and psychologist; and set up referral relationships with a number of specialists.
  • Initial and ongoing training of health coaches: The health coaches received formal training from Renaissance Health on the management of specific chronic conditions, relevant clinical skills (e.g., how to take blood pressure), and patient engagement strategies, such as motivational interviewing and how to identify and address barriers to care. Weekly training sessions serve as ongoing "refreshers" for advisors; they cover a wide range of clinical topics, such as specific chronic care issues (e.g., foot examinations for diabetes patients), addiction, and comorbidities and complications associated with chronic illnesses. 
  • Creating communication plan with hospital: AtlantiCare and Renaissance Health representatives arranged for the hospital to notify the practice every time one of its patients entered the hospital or visited AtlantiCare's ED. 
  • Adopting information technology: The practice purchased an EMR to facilitate communication and documentation and developed a Web-based patient registry to facilitate disease management.
  • Inviting initial patients to join: As described earlier, AtlantiCare and the Fund ran a predictive model to identify medically complex patients expected to incur the highest health care costs. They then invited these patients to join the practice. After the project launch, patients were also identified in the hospital and self-referred.

Resources Used and Skills Needed

  • Staffing: The practice is staffed by two full-time equivalent physicians; a nurse practitioner; six health coaches (with credentials ranging from community health worker to registered nurse); two front-desk staff; an administrative director; a half-time data analyst; and a part-time social worker, nutritionist, and psychologist. Each health advisor handles an active caseload of 150 to 200 patients at a time.  
  • Costs: Data on program costs are unavailable; the primary costs consist of salary and benefits for center staff, administrative costs, and overhead. The cost of running the center is roughly double that of a traditional, comparably-sized primary care practice; however, cost savings generated by fewer hospitalizations and ED visits more than make up for these higher operating costs.
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Funding Sources

AtlantiCare; Hotel Employees and Restaurant Employees International Union Welfare Fund
Instead of paying for each encounter under a FFS methodology, the payers pay a monthly per-patient (capitated) fee to cover all primary care services. To improve access to care for the union's low-wage population, the fund does not require a copayment for office visits or prescriptions filled at the practice's onsite pharmacy.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Hire health coaches who can relate to patients: Health coaches who have personal or familial experience with chronic disease can often connect effectively with patients suffering from the same kinds of conditions. In addition, health coaches should come from similar communities and cultures as the patients they serve.
  • Embrace new methods of payment: FFS payment systems do not reimburse practices for ongoing, cost-effective interactions (e.g., phone calls or e-mails) that offer meaningful, timely support to chronic disease patients between office visits. To avoid this problem, partner with payers willing to consider global fees that encourage flexibility in how care is provided, with a focus on overall care rather than billable events.
  • Consider merits of EMR: Some EMRs may not be designed to support the workflow of this type of practice. The Special Care Center adopted an EMR to document visits, but found that it (like other commercially available EMR products) did not fit well with the practice's workflow. As a result, the center began using additional technologies to meet its needs, including a Web-based data registry to track patient care and Microsoft Word to create care plans. 

Sustaining This Innovation

  • Pursue ongoing process improvement: The Special Care Center represents a work in progress that continually evolves based on ongoing reviews of center operations and practitioner interactions with patients. To that end, center leaders regularly seek to identify opportunities to enhance operational, service, and care quality. For example, they have considered the types of group visits to hold, the best methods for provider-patient communication, and the best way to organize the daily huddles and track data. 
  • Provide ongoing training: Regular training sessions help to ensure that health advisors maintain their clinical knowledge and professional enthusiasm.

Use By Other Organizations

The A-ICU model, on which the Special Care Center is based, has been used by a small number of other progressive payers and providers in the United States. The Boeing company sponsored a pilot for its sickest patients with three large medical groups in the Puget Sound, WA area; this also showed improved outcomes and lowered net health care costs.5 The Union Health Center in New York, NY also has implemented this model with a union population.6

More Information

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Contact the Innovator

Pranav Kothari, MD
Renaissance Health
One Broadway, 14th floor
Cambridge, MA 02142
Phone: (617) 682-3668

Innovator Disclosures

Dr. Kothari has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Fernandopulle R, Patel N. How the electronic health record did not measure up to the demands of our medical home practice. Health Aff (Millwood). 2010 April;29(4):622-8. [PubMed]


1 U.S. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. The Power of Prevention. 2009. Available at:
2 Center for Healthcare Research & Transformation. Health Care Cost Drivers: Chronic Disease, Comorbidity, and Health Risk Factors in the U.S. and Michigan. August 3, 2010. Available at:
3 Agency for Healthcare Research and Quality. The High Concentration of U.S. Health Care Expenditures. Research in Action. Issue #19. June 2006. Available at:
4 California HealthCare Foundation. Challenging the Status Quo in Chronic Disease Care: Seven Case Studies. September 2006. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)
5 Are Higher Value Care Models Replicable? Health Affairs Blog. October 20, 2009. Available at:
6 Nelson K, Pitaro M, Tzelllas A, et al. Practice profile. Transforming the role of medical assistants in chronic disease management. Health Aff (Millwood). 2010;29(5):963-5. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 22, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 17, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.