Community Care Outcomes
Institute Summary: Unit Overview
Cleveland Clinic’s Community Care Unit brings together functions that partner to provide exceptional care that is personalized, respectful and affordable for patients and the communities served, built on a foundation of engaged caregivers who are guided by transformative research and education. This includes the alignment of Value Based Operations, Clinical Operations, and Community Health and Relations to impact all aspects of care for our patients and communities.
Community Care's Clinical Operations include departments that provide coordinated care across the practices of adult and pediatric primary care, consultative internal medicine, geriatrics, hospital medicine, medical care at home, genomics, functional medicine, and wellness and preventative medicine. These teams serve patients during their lifetime and reach across multiple venues to provide continuity throughout the continuum of care.
Community Care's Value-Based Operations team is designed to encourage the patient-and caregiver-centered team care model through multidisciplinary collaboration with partners in Ambulatory Care Management and Nursing, Regional Primary Care, Care at Home, Clinical Contracting and Plan Leadership, Population Health IT & Analytics, Quality & Safety, Specialty Institutes, and Practice Improvement & Care Model Innovation. These care teams focus on optimizing patient outcomes by managing a patient's health, wellness, and chronic diseases in a more effective, coordinated, and proactive way. The ultimate goal is to improve the quality of care, provide an unparalleled patient experience, and decrease the cost of care.
The Community Health team works to support Cleveland Clinic facilities (eg, primary care physicians) and community partners to routinely and effectively address patients' social needs. Social needs are nonmedical aspects of individual and family lives that can affect one's ability to maintain health and well-being. The Community Health team focuses on addressing social needs including housing (stability and quality); food (stability and security); legal needs related to immigration status, eligibility for public health insurance, employment, family, and/or housing access; and government benefits access for income maximization and other needs. Additionally, the team oversees the community health strategy and implementation for each region (south, west, east central) and key strategies (adult, youth, public health aligned with community health needs assessment, and anchor institution strategies).
The Community Care Unit strives to be the medical home for accessible, comprehensive, coordinated, high-quality, cost-effective care. Community Care has family medicine, internal medicine, and pediatric physicians at 20 family health centers, 8 regional hospitals, and 60 regional primary care practices. Hospital medicine physicians are at 6 regional hospitals. In addition, the Executive Health program combines world-class health care and wellness services to provide the most comprehensive, streamlined executive health physical examination available, tailored to patients’ own specific needs, which transforms the traditional physical examination into an integrated, personalized, head-to-toe evaluation that includes appointments with experts in nutrition, exercise physiology, and stress management, plus vision, hearing, heart health, and lung function assessments, and more. The Executive Health program is offered in Cleveland, as well as in Toronto, Florida, and Abu Dhabi. Combined, the programs have relationships with over 400 companies and more than 7000 patients are seen annually.
Key programs include the following:
- Center for Geriatric Medicine, ranked 2nd as one of the nation’s top geriatric centers by U.S. News & World Report
- Center for Value-Based Care Research, aimed at studying new models of healthcare
- Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center for preoperative consultation and care
- Primary Care Women’s Health program for gender-specific care, education, and research
- Medicare Accountable Care Organization (ACO), which currently manages a population of 95,000 patients across Northeast Ohio and is one of the largest in the country
- Weight Management Navigation program for triage of patients into a program that best fits individual preferences
- Best Buy® Remote Monitoring Blood Pressure Pilot, which resulted in providers finding value in remote monitoring for their patients and identified opportunities to explore for further mobilization and expansion of this type of service
- Ambulatory Care Management, which consists of four key members of the care team, including Primary Care Coordination, Primary Care Social Work, Population Health Navigation, and the RN Contracting Team
- The inSight Community Monitoring Program, developed to ensure the proactive management of at-risk populations in the midst of the COVID-19 pandemic. This includes patients who test positive for or are suspected of having COVID-19, patients with chronic diseases that are considered high risk, and patients recently discharged from the hospital
- Transitional Care Management Home Visit program, which consists of a series of post discharge in-home visits with Advanced Practice Nurses and Community Paramedics from the Medical Care at Home team for patients with a high risk of readmission
- Virtualist Program, which consists of providers who utilize telehealth tools/technologies to reduce inappropriate emergency department and inpatient utilization and safely navigate patients to the appropriate levels of care. Target support areas for second level triage/deescalation include patients identified as needing emergency services from Nurse-on-Call, Family Health Centers, Express Care, Home Health, and the inSight Community Monitoring Program
|Physicians||Advanced Practice Providers||Volumes|
|Primary care - Ohio 390||Primary care - 148||Primary care — Ohio 1,113,442|
|Hospital medicine - 180||Hospital medicine - 37||Hospital medicine (IMPACT) 18,282|
|Inpatient admissions — Ohio 30,103|
|Express care 11||Express care 195||Express care 337,144|
|Geriatrics 12||Geriatrics 3|
|Wellness 13||Wellness 2||Wellness 10,442|
|Medical care at home 11||Medical care at home 14||Medical care at home 1301|
|Executive health 8||Executive health 0||Executive health 1627|
|Primary care, women’s health 31||Primary care, women’s health 1|
|Residents and fellows 207||Residents and fellows 0|