About the Program

The California HealthCare Foundation (CHCF) and California Quality Collaborative (CQC) are partnering to convene a Complex Care Management Action Community. While much is known about how to care for patients with single chronic conditions, such as diabetes or heart disease, less is known about how to manage high-cost patients with multiple and complex chronic conditions. However, some organizations in California are already testing a range of practices and approaches to better manage a high-cost, medically complex patient population - the Action Community will bring together these organizations with experience caring for medically complex patients to learn about, share, and test improvements in care that lead to better health outcomes at lower cost.

The Action Community is a year-long program for organizations with experience caring for medically complex patients to learn about, share, and test improvements in care that lead to better health outcomes at lower cost. The Action Community is offered at no charge to 7-10 organizations selected via a brief application process to achieve a balanced mix of organization type and location and to ensure that the participating organizations have demonstrated experience testing care improvements in a population with complex medical needs.

Benefits

Participants will benefit through:

• Access to California and national experts with knowledge and expertise in managing high-cost, medically complex populations (experts will be selected based on input from Action Community members)
• Facilitated peer learning among organizations within the Action Community
• Expert faculty consultation and coaching to assist with tests of change in care management
• Ability to influence and tailor meeting and teleconference content to meet the needs of the community

In exchange, participants are asked to:

• Based on learning within the community, strengthen or refine complex care management practices already in place and/or test new components of care management
• Attend in-person sessions and teleconferences to openly share learning and results of tests of change, including specific care processes, challenges, and successful practices for staffing, data management, patient engagement, physician involvement, coordination of care and transitions of care
• Using your organization's existing processes of reporting and monitoring outcomes for a high-cost population (measures will not need to be standardized across organizations and will not be shared outside the community), share data on measures 1-3 for the target population twice during the Action Community (six months into the community and at its conclusion). Sharing data on measures 4 and 5 is optional.
  1. Hospital admissions
  2. Emergency department utilization
  3. Clinical quality measures appropriate for your target population (such as medication adherence, disease-specific screening or control measures, etc.)
  4. Patient experience or functional status (optional)
  5. Provider experience/feedback (optional)

Approach

Over the course of one year, the Action Community will participate in shared learning via:

• Three all-day in-person sessions, alternating between southern and northern California
• Teleconference calls, as needed, to supplement learning and information exchange for the entire community and/or for specific subgroups of organizations

Participants

The following organizations were selected to participate in the Action Community in 2011:

• Bristol Park Medical Group
• CalOptima
• Central California Alliance for Health
• HealthCare Partners
• High Desert Medical Group
• Humboldt Del Norte IPA/Foundation
• PrimeCare
• St. Joseph Heritage Medical Group

Sophia Chang, MD, Director, California HealthCare Foundation, will serve as the Action Community's physician lead and Giovanna Giuliani, Senior Manager, California Quality Collaborative, will serve as the Action Community's project director.

Program Materials