Mayo Clinic Proceedings Home

Care Coordination for Patients With Complex Health Profiles in Inpatient and Outpatient Settings

Published:January 07, 2013DOI:


      Patients with the most complex health profiles consume a disproportionate percentage of health care expenditures, yet often receive fragmented, suboptimal care. Since 2003, Wisconsin-based Gundersen Health has improved the quality of life and reduced the cost burden of patients with complex health profiles with an integrated care coordination program. Those results are consistent with data from the most successful care coordination demonstration projects funded by the Centers for Medicare and Medicaid Services. Specifically, Gundersen's program has been associated with reduced hospital stays, lower costs for inpatients, less use of inpatient services, and increased patient satisfaction. Gundersen's success is rooted in its team-based approach to coordinated care. Teams, led by a subspecialty-trained nurse, have regular, face-to-face contact with patients and their physicians in both inpatient and outpatient settings; involve patients deeply in care-related decisions; access a system-wide electronic medical record database that tracks patients' care; and take a macrolevel view of care-related factors and costs. Gundersen's model offers specific take-home lessons for institutions interested in coordinated care as they design programs aimed at improving quality and lowering costs. This institutional case study provides a window into well-executed care coordination at a large health care system in an era when major changes in health care provision and reimbursement mechanisms are on the horizon.

      Abbreviations and Acronyms:

      CMS ( Centers for Medicare and Medicaid Services), EMR ( electronic medical record)
      To read this article in full you will need to make a payment


        • Agency for Healthcare Research and Quality
        The high concentration of U.S. health care expenditures.
        Res Action. 2006; 19 (Accessed January 31, 2012)
        • Emanuel E.J.
        Where are the health care cost savings?.
        JAMA. 2012; 307: 39-40
        • Gawande A.
        “The hot spotters.”.
        The New Yorker. 2011; 86: 40-51
        • Tinetti M.E.
        • Fried T.R.
        • Boyd C.M.
        Designing health care for the most common chronic condition—multimorbidity.
        JAMA. 2012; 307: 2493-2494
        • Blumenthal D.
        Performance improvement in health care—seizing the moment.
        N Engl J Med. 2012; 366: 1953-1955
        • Berwick D.M.
        • Nolan T.W.
        • Whittington J.
        The triple aim: care, health, and cost.
        Health Aff (Millwood). 2008; 27: 759-769
        • Craig C.
        • Eby D.
        • Whittington J.
        Care Coordination Model: Better Care at Lower Cost for People With Multiple Health and Social Needs. IHI Innovation Series white paper.
        Institute for Healthcare Improvement, Cambridge, MA2011 (Accessed February 1, 2012)
        • Berwick D.M.
        • Hackbarth A.D.
        Eliminating waste in US health care.
        JAMA. 2012; 307: 1513-1516
        • National Quality Forum
        Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination.
        National Quality Forum, Washington, DC2010
        • Owens M.K.
        Costs of uncoordinated care.
        in: Yong P.L. Saunders R.S. Olsen L.A. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. National Academy Press, Washington, DC2010: 109-140
        • Peikes D.
        • Chen A.
        • Schore J.
        • Brown R.
        Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.
        JAMA. 2009; 301: 603-618
        • Brown R.S.
        • Peikes D.
        • Peterson G.
        • Schore J.
        • Razafindrakoto C.M.
        Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients.
        Health Aff (Millwood). 2012; 31: 1156-1165
        • Dorr D.
        • Wilcox A.B.
        • Brunker C.P.
        • Burdon R.E.
        • Donnelly S.M.
        The effect of technology-supported, multi-disease care management on the mortality and hospitalizations of seniors.
        J Am Geriatr Soc. 2008; 56: 2195-2202
        • Counsell S.R.
        • Callahan C.M.
        • Clark D.O.
        • et al.
        Geriatric care management for low-income seniors: a randomized control trial.
        JAMA. 2007; 298: 2623-2633
        • Counsell S.R.
        • Callahan C.M.
        • Tu W.
        • Stump T.E.
        • Arling G.W.
        Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention.
        J Am Geriatr Soc. 2009; 57: 1420-1426
        • Peikes D.
        • Peterson G.
        • Brown R.S.
        • Graff S.
        • Lynch J.P.
        How changes in Washington University's Medicare coordinated care demonstration pilot ultimately achieved savings.
        Health Aff (Millwood). 2012; 31: 1216-1225
        • Mays G.P.
        • Au M.
        • Claxton G.
        Convergence and dissonance: evolution in private-sector approaches to disease management and care coordination.
        Health Aff (Millwood). 2007; 26: 1683-1691
      1. Johns Hopkins: Care Coordination Tier Assignment Tool, Version 1.0, Health Care Home Initiative: Minnesota Department of Human Services; Health Care Homes (HCH), Eligible Recipients: Care Coordination Tier Assignment Tool. August 17, 2010. Accessed March 19, 2012.

        • Katon W.J.
        • Lin E.H.
        • Von Korff M.
        • et al.
        Collaborative care for patients with depression and chronic illnesses.
        N Engl J Med. 2010; 363: 2611-2620
        • Grant R.W.
        • Ashburner J.M.
        • Hong C.S.
        • Chang Y.
        • Barry M.J.
        • Atlas S.J.
        Defining patient complexity from the primary care physicians perspective: a cohort study.
        Ann Intern Med. 2011; 155: 797-804
      2. NCQA standards: QI 7: Complex Case Management Standards and Guidelines. 2012. Accessed March 19, 2012.

        • Wasson J.H.
        • Ahles T.
        • Johnson D.
        • Kabcenell A.
        • Lewis A.
        • Godfrey M.M.
        Resource planning for patient-centered, collaborative care.
        J Ambul Care Manage. 2006; 9: 207-214
        • Detsky A.S.
        What patients really want from health care.
        JAMA. 2011; 306: 2500-2501
        • Bintz M.
        • Tucker L.
        • Lachman V.
        • Bahr J.
        • Larson D.
        Transformational patient care: a system of care coordination that works.
        Grp Prac J. 2009; 8: 15-18
        • Doty M.M.
        • Fryer A.K.
        • Audet A.M.
        The role of care coordinators in improving care coordination: the patient's perspective.
        Arch Intern Med. 2012; 172: 587-588
        • Weppner W.G.
        • Coleman K.
        • Reid RJ.
        • Larson EB.
        Improving management of chronic disease.
        in: From Front Office to Front Line: Essential Issues for Health Care Leaders. 2nd ed. Joint Commission, Washington, DC2011: 127-158
        • Bodenheimer T.
        • Chen E.
        • Bennett H.D.
        Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job?.
        Health Aff (Millwood). 2009; 28: 64-74
        • Sochalski J.
        • Jaarsma T.
        • Krumholz H.M.
        • et al.
        What works in chronic care management: the case of heart failure.
        Health Aff (Millwood). 2009; 28: 179-189
        • Ayanian J.Z.
        The elusive quest for quality and cost savings in the Medicare program.
        JAMA. 2009; 301: 668-670
        • Rich E.C.
        • Lipson D.
        • Libersky J.
        • Peikes D.N.
        • Parchman M.L.
        Organizing care for complex patients in the patient-centered medical home.
        Ann Fam Med. 2012; 10: 60-62
        • Coleman K.
        • Mattke S.
        • Perrault P.J.
        • Wagner E.H.
        Untangling practice redesign from disease management: how do we best care for the chronically ill?.
        Annu Rev Public Health. 2009; 30: 385-408
        • Milstein A.
        • Gilbertson E.
        American medical home runs.
        Health Aff (Millwood). 2009; 28: 1317-1326
        • Berry L.L.
        The best companies are generous companies.
        Business Horizons. July-August 2007; 50: 263-269
        • Hauer K.E.
        • Durning S.J.
        • Kernan W.N.
        • et al.
        Factors associated with medical students' career choices regarding internal medicine.
        JAMA. 2008; 300: 1154-1164