Why It Matters
In the year after enrollment, San Francisco Health Network's Complex Care Management patients had 52 percent fewer hospital days and 24 percent fewer ED visits.
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How to Improve the Health of Patients with Complex Care Needs

By Elizabeth Davis | Monday, June 22, 2015

To prevent unnecessary hospitalizations and ED visits for patients with complex care needs, San Francisco Health Network (SFHN) has established interdisciplinary complex care management teams, in which they embed nurse care managers, health coaches, social workers, and others in primary care health centers to provide additional “wraparound services” for patients. Elizabeth Davis, MD, Medical Director of Care Coordination for SFHN Primary Care, describes how program patients’ hospital days dropped 52 percent and ED visits reduced 24 percent after enrollment in SFHN’s Complex Care Management program. SFHN is one of a cohort of safety net organizations sponsored by the California HealthCare Foundation to participate in IHI’s Better Health and Lower Costs for Patients with Complex Needs Collaborative.

Mr. G. is a 48-year-old man diagnosed with congestive heart failure, severe coronary artery disease, and chronic obstructive pulmonary disease who also suffers from depression and addiction to methamphetamines. Prior to enrolling in the San Francisco Health Network (SFHN) Primary Care’s Complex Care Management program, San Francisco General Hospital admitted him three times in one year for a total of 23 hospital days. While Mr. G had areas of strength – including high motivation to improve his health and his ex-wife providing active social support – he was also looking for help to address his addiction, take his medications regularly, and organize his medical care. 

The SFHN, the San Francisco Department of Public Health’s integrated system of health care delivery, is committed to improving care by using integrated data systems to identify high-risk patients (like Mr. G), and comprehensive case management for homeless clients and frequent  users of the emergency department. More recently, the Network’s efforts have included complex care management for high-risk patients in primary care, who often need significant support from the health care system. 

Preventing Hospitalizations and ED Visits
The goal of SFHN Primary Care’s Complex Care Management program is to prevent unnecessary hospitalizations and emergency department visits by helping patients to be healthier. Our approach emphasizes interdisciplinary complex care management teams embedded in SFHN’s primary care health centers. The first team launched in February 2012 in the General Medicine Clinic, three more teams launched in community-based clinics in 2013, and a fifth team is launching in Fall 2015. Teams include full-time nurse care managers and health coaches supported by part-time social workers. A coordinator and medical director also support the teams. Patients are identified through utilization data provided by both San Francisco General Hospital and San Francisco Health Plan (the local Medicaid managed care plan), as well as through provider referral. Patients in the program keep their established primary care provider and receive additional wraparound services from the complex care management team, including an in-home comprehensive assessment, patient-centered care plan, and coaching toward care plan goals.

When SFHN joined the
IHI Better Health and Lower Costs for Patients with Complex Needs Collaborative in 2014, we were at a major transition point: we had evaluated our successes and challenges over the previous two years and were ready to integrate and standardize the work of our complex care management teams, so that we were one cohesive program. As part of the Collaborative, we conducted in-depth interviews with patients and providers, analyzed our data, and forged partnership with stakeholders. Through this process, our learnings informed improvements to the program. 

Patient and Family Feedback
From patient interviews and our review of the literature, we learned we had to start by building trusting relationships before moving on to coaching patients around clinical goals. Consequently, our first step is now to ask patients how we can help them meet the goals they have for themselves. This can take intensive work initially, especially because some patients are not sure they can trust us. Even if patients don’t initially engage with us, they may change their minds after we demonstrate that we are trustworthy and know how to listen.

Patients told us that self-management coaching helped them feel more in control – once they understood what steps to take to manage their illness, they no longer felt helpless. Engaging and coaching patients’ caregivers has also been successful as it has helped them feel more empowered to help the patients. Patients also told us that they valued how the care team helped remove barriers to care and helped them navigate the complex medical and behavioral health care systems.

earning from Data
Data taught us several interesting lessons. When we evaluated our frequently-hospitalized patients, for example, we found that 84 percent were concentrated in six of our 15 primary care health centers. Two of these health centers already had programs in place for high-risk patients, so using this data, we decided to focus our efforts to improve complex care management in the remaining four clinics.

The data also showed that only 1 percent of the frequently-hospitalized patients in our primary care network accounted for 50 percent of the days our primary care patients spent in the hospital. The top three admission diagnoses – accounting for 27 percent of admissions – were congestive heart failure, angina, and pneumonia. These conditions are often managed effectively on an outpatient basis and these hospitalizations may have been preventable with better ambulatory care.

The SFHN Complex Care Management team now targets patients who have been hospitalized three or more times in the past year and those identified by providers or clinic staff as being at high risk of frequent hospitalization in the future. Once we have this list of patients, we look in a centralized San Francisco Department of Public Health database to identify what other services the patient receives. If the patient already has intensive case management, we do not enroll the patient in our Complex Care Management program.


Over the course of the IHI Collaborative, we’ve faced a variety of staffing issues, including turnover, leaves, new hiring, and three teams moving to different primary care clinics. Consequently, we found ourselves in the midst of a natural “experiment” in which we had one nurse working with four health coaches instead of the initial model we developed with one nurse for every health coach. We learned from the Collaborative that many organizations staff their programs primarily with health workers, so we saw our circumstances as an opportunity to try this model. Ultimately, we found that our patients are so medically frail that they frequently needed nursing intervention, and thus we returned to our original model. 

Patient Recruitment

Because the nurse and health coach teams were so busy with current patients, they had little time to recruit new patients into the program. We tested an idea (learned from another Collaborative team) of dedicating one person’s time to coordinating all recruitment and enrollment visit scheduling. This new staff role – and the hiring of two additional nurses – has helped increase enrollment in the program. Once we have a full staff of five nurse/health coach teams, our overall goal is to have 250 active patients in the program.

Results and Lessons Learned

We’re proud that outcomes data from our General Medicine Clinic team shows that, in the year after enrollment in the Complex Care Management progra
m, patients have 52 percent fewer hospital days and 24 percent fewer ED visits compared to the year prior to enrollment. Our other teams started enrolling only recently, so we do not yet have outcomes data for their patients yet. 


Here are some of the most important lessons we learned thus far:
  • Nurse-led interdisciplinary teams embedded in primary care can dramatically decrease admissions and ED visits for high-risk patients.
  • Trained health coaches can be very effective at improving patient self-management and assisting with navigational issues, allowing the nurse time to focus on more complex clinical issues. 
  • Effective care coordination is time intensive.
  • Trusting relationships with patients are the basis for effective self-management coaching.
  • Good data systems can expand capacity and lower team stress by helping target limited resources most effectively.

What we learned from participating in the IHI Collaborative has helped us formalize our learning systems for testing and spreading new processes. We incorporated the idea of continuous improvement, which we learned from the Collaborative, into our team philosophy: we trust, support, and respect each other, while welcoming new ideas and feedback, in order to provide the best care possible for our patients. We believe this philosophy helps both our patients and our team.

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