Institute Summary: Unit Overview

Cleveland Clinic’s Community Care Unit brings together departments that provide coordinated care across the practices of adult primary care, family medicine (including the care of children and adolescents), primary pediatrics, consultative internal medicine, geriatrics, hospital medicine, medical care at home, and wellness and preventative medicine. From establishing outpatient care with new physicians to ensuring effective inpatient care through hospital medicine, and taking care to the patient through medical care at home consultants, the Community Care Unit has the expertise to deliver outstanding care and achieve superior outcomes.

The Community Care Unit strives to be the medical home for accessible, comprehensive, coordinated, high-quality, cost-effective care for patients that seeks to drive value across the continuum of care for each patient touched. Based at Cleveland Clinic’s main campus, Community Care has family medicine, internal medicine, and pediatric physicians at 16 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:

  • The new Value Based Operations structure, improving the patient- and caregiver-centered team care model through multidisciplinary collaboration with partners in Ambulatory Care Management and Nursing, IT, Population Health Analytics, Clinical Contracting and Plan Leadership, Quality, Specialty Integration, Medical Neighborhood, and Care Model Innovation
  • Center for Geriatric Medicine, ranked 5th 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 100,000 patients across Northeast Ohio and Florida 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
  • Smoking Cessation 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 4 key members of the care team, including primary care coordination, primary care social work, navigation, and an RN central team
  • Transitional Care Management Home Visit program, which consists of a series of post discharge in-home visits with an APRN/paramedic team for high risk patients

PhysiciansAdvanced Practice ProvidersVolumes
Primary care - Ohio 338Primary care - 112Primary care — Ohio 1,088,049
Hospital medicine - 155Hospital medicine - 32Hospital medicine (IMPACT) 17,535
Inpatient admissions — Ohio 26,756
Express care 8Express care 155Express care 295,474
Geriatrics 8Geriatrics 2
Wellness 14Wellness 2Wellness 11,736
Medical care at home 8Medical care at home 12Medical care at home 2244
Executive health 6Executive health 0Executive health 1706
Primary care, women’s health 35Primary care, women’s health 1
Residents and fellows 170Residents and fellows 0