1. Building an intensive primary care practice
Provide better care for patients who need it most

2. Comprehensively address the goals and medical needs of patients with multiple chronic conditions whose needs cannot be met in a short primary care visit

3. $$$$$ =
A small percentage of patients account for a large percentage of health care costs in a given year.

4. Eight steps to implementing intensive primary care in your practice1
Identify the target patient population 2
Assess the target patient population 3
Compose the appropriate care team 4
Appropriately engage patients

5. Eight steps to implementing intensive primary care in your practice5
Design the patient-centered care model 6
Build the team 7
Implement the new model 8
Track outcomes

6. How is it working at other practices?
Palo Alto, CA
Steps in Practice Summary = Stanford Coordinated Care in Palo Alto, CA
Primary care clinic for Stanford employees and dependents on the self-insured health plan who are at high risk for poor (and expensive) outcomes
Co-directors designed a fully capitated care model based on extensive interviews with 34 Stanford employees with chronic health conditions, in which they shared what worked for them and what they found challenging in achieving the best health possible
Physician panels are limited to 300 panels; MA care coordinators have 100 patients per panel
SCC model of care
Huddle each morning to review the day’s schedule for potential snags, plan for procedures and review timing of slots reserved for acute visits (handled by both care coordinator and physician)
PCP, care coordinator work together to complete intake, as well as to understand specific challenges that patient is facing
Care coordinator checks patient understanding, reviews action plans, etc.
Care is focused first and foremost on addressing patients’ self-identified goals
Team is built for success
Weekly clinical and operations meetings are held for all team members
Teams help to decide who should become involved in each patient’s care going forward
Model is capitated for services it provides
Paid by the month, which protects the longer-visit model
Everything is sent through the secure patient portal online
SCC uses dashboards that draw from their HER
Care gaps dashboard about routine tests and immunizations that are due
Risk dashboard identifies patients who are high risk for poor and expensive outcomes

7. For additional resources, frequently asked questions and implementation support, visit