Institute Summary: Unit Overview

Cleveland Clinic’s Community Care Unit brings together functions that partner to provide exceptional care that is personalized, equitable, and accessible for patients and the communities served. These functions are built on a foundation of engaged caregivers who are guided by transformative research and education. As a multidisciplinary and multifunctional care team, Community Care’s operations are across 20 family health centers, 8 regional hospitals, and 60 regional primary care practices and caring for all of our communities across Northeast Ohio.

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, clinical 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. Their scope is to support the empaneled patients of our primary care teams. Using data to target improvement and patient engagement, these care teams focus on optimizing patient outcomes, quality, and cost through proactive management of a patient's health, wellness, and chronic diseases.

The Community Health and Partnerships team works to bridge clinical efforts with community needs by leveraging internal capabilities and engaging community partners to assist with removing barriers to care which often include social needs. Social needs are nonmedical aspects of individual and family lives that can affect one's ability to maintain health and well-being. These could include 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.

The capabilities in Clinical Operations, Value-Based Operations, and Community Health and Partnerships are synchronously deployed to enable excellent and focused longitudinal care for patients and communities.

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
  • Primary Care Women’s Health program for gender-specific care, education, and research
  • Medicare Accountable Care Organization (ACO), which currently manages a population of 85,000 patients across Northeast Ohio and is one of the largest in the country
  • Enterprise Weight Management Center, established to connect patients and their primary and specialty providers with comprehensive and evidenced-based care, resulting in clinically meaningful health outcomes; a navigation program was initiated for triage of patients into a weight management and nutrition program that matches the patients' preference
  • Smoking Cessation Navigation program for triage of patients into a program that best fits individual preferences
  • The Executive Health program combines world-class health care and wellness services to provide the most comprehensive, tailored, streamlined executive health physical examination available. The approach transforms the traditional physical examination into an integrated, personalized, head-to-toe evaluation. This service is offered in Cleveland, Toronto, Florida, and Abu Dhabi. Combined, the programs have relationships with over 400 companies and more than 7000 patients are seen annually.
  • Ambulatory Care Management, which consists of 4 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 who are considered high risk, and patients recently discharged from the hospital
  • Transitional Care Management Home Visit program, which consists of a series of postdischarge 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
  • Medical Neighborhoods established in partnership with specialty colleagues to support seamless patient care, including Heart Failure, Chronic Kidney Disease, and COPD
  • Program initiated that allowed COVID+ patients a fast track to home with oxygen to avoid unnecessary hospitalization
  • In partnership with VNA offered behavioral health services to homebound patients
  • Home Monitoring Program offered to COVID+ patients, which involved technology-driven check-ins along with caregiver phone calls for specific patient populations
  • Genetic counseling services provided to pediatric and adult patients
  • Focused on patient and caregiver wellness via life style, integrative, and functional medicine services
PhysiciansAdvanced Practice ProvidersVolumes
Primary care, Ohio: 379Primary care: 173Primary care, Ohio: 1,006,979
Hospital medicine: 173Hospital medicine: 60Inpatient admissions, Ohio: 30,763
Express care: 8Express care: 199Express care: 197,556
Geriatrics: 11Geriatrics: 1Geriatrics: 9754
Wellness: 11Wellness: 1Wellness: 6858
Medical care at home: 13Medical care at home: 13Medical care at home: 11,523
Executive health: 8Executive health: 0Executive health: 1137
Residents and fellows: 227Residents and fellows: 0
Functional medicine: 10Functional medicine: 3Functional medicine: 9267
Genomics: 13Genomics: 0Genomics: 1165
Attributed Lives: 440,000