Commonwealth Care Alliance

Leadership in Complex Care

Leadership in Complex Care

Our nationally recognized expertise in complex care traces back to the mission of our founders. A group of community doctors, nurse practitioners, and healthcare advocates, they created a new way to provide care for the most vulnerable adults in our communities. These were individuals living with multiple chronic medical conditions, many of whom who also had behavioral health issues and social challenges.

Our founders knew that people with advanced and complex illnesses needed comprehensive, integrated care delivery and coordination. And that is exactly the care model that we developed. Our approach to care has led the way for a national transformation in care delivery for people with complex healthcare challenges.

Adults of all ages with complex healthcare needs may be:
  • Individuals who have mobility challenges
  • Frail with progressive or chronic physical disability
  • Users of home health and long-term services and supports
  • At risk for acute episodes
  • Challenged by severe, persistent mental illness and often admitted to inpatient psychiatric facilities
  • Lacking in a strong social network
  • Frequent users of emergency room services
  • Challenged by issues such as substance use, trauma, and homelessness
  • Challenged by end-of-life needs for multiple hospitalizations, nursing home stays, and increasing home health needs

Meet "Jack": a Profile in Complex Care

This patient profile illustrates complex care needs consistent with those of actual CCA members. Jack's profile is that of a 55-year-old active smoker with:

  • Traumatic brain injury
  • Schizophrenia
  • Seizure disorder
  • Morbid obesity
  • Hypertension
  • High cholesterol
  • Chronic hepatitis C
  • Diabetes
  • Chronic obstructive pulmonary disease (COPD)

Jack has impaired cognition, but is considered competent to make his own medical decisions. He lives in a group home and can manage activities of daily living on his own, as long as he gets frequent prompting.

Before CCA

Jack’s care was extremely fragmented. He had acute behavioral episodes. His weight was climbing, and his behavior was challenging.

  • Saw an average of eight different outpatient providers a year
  • Had 10 inpatient admissions in the prior year, half psychiatric, half acute medical, with each admission typically lasting 5 to 10 days
  • Had been to the emergency room 22 times in the prior year with a variety of complaints
  • Took 15 medications daily, including three antipsychotics, but was only intermittently adherent
  • Jack visited his primary care provider (PCP) monthly for medication refills, but his PCP was often not notified of Jack’s acute behavioral visits
  • His PCP had never spoken to his behavioral provider and could not view Jack’s behavioral health records
  • Jack had a community case worker through his mental health provider who was not in communication with Jack's other providers.

After CCA

Jack now has a single, integrated care system. His CCA care manager is a nurse practitioner who can make home visits and coordinate with his primary care doctor and specialists.

  • Has a dedicated, interprofessional care team that provides early engagement and identification of medical issues before they become emergencies
  • Continues to see his behavioral health provider, and when he starts to realize he needs additional support or has a psychiatric emergency he is admitted to a CCA Crisis Stabilization Unit in the community
  • Has a simplified medication list, and meds are delivered in blister packs to his home
  • A health outreach worker checks in regularly and accompany Jack to important medical appointments
  • A personal care worker visits three time per week to help with activities of daily living, homemaking, and laundry
  • A nurse practitioner or physician’s assistant makes home visits in response to urgent needs or to help manage Jack’s hypertension
  • Home visits by a nurse practitioner or physician’s assistant help Jack avoid health complications that could result in a hospital admission
  • Enrolled in a day program where he can socialize with peers and engage in activities
  • His primary care provider is able to provide screening and preventive care for his chronic conditions
  • All of Jack’s health information is contained within a single integrated record accessible to all of his providers and his care team

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