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Service Delivery Innovation Profile

Intensive Case Management Reduces Inpatient Admissions and Emergency Department Visits Among Costly, Medically Complex Patients Without Insurance

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The University of New Mexico Health Sciences Center's Care One program provides intensive case management and care coordination services to costly, medically complex patients who lack insurance. The program assigns each enrolled patient to a physician-led team of providers, including a social worker and behavioral health specialist, who help the individual navigate the health care system, access available financial assistance, and utilize appropriate community resources. The program has significantly reduced inpatient admissions and emergency department visits and led to high levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of inpatient admissions and emergency department (ED) visits, along with anecdotal feedback from program participants.
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Developing Organizations

University of New Mexico Health Sciences Center
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Date First Implemented

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Patient Population

Vulnerable Populations > Medically or socially complex; Medically uninsured; Insurance Status > Uninsuredend pp

Problem Addressed

Medically complex patients at risk for catastrophic health events make up only a small fraction of the entire patient population but account for a disproportionate share of spending.1,2 These patients usually have difficulty navigating the health care system and thus receive inadequate care, making them vulnerable to severe, costly medical crises.
  • High utilization among few patients: Health care utilization and costs are often highly concentrated among a relatively small group of high-risk, medically complex patients, many of whom are facing a combination of chronic physical and behavioral health issues. These patients are estimated to comprise between only 0.5 and 1 percent of the general patient population but represent 20 to 30 percent of all hospital admissions and 20 to 25 percent of all medical costs.1
  • Difficulty navigating system, leading to more emergency care: Due to the complexity of their circumstances, these high-risk patients often have difficulty accessing and navigating the health care system. Consequently, they may not seek medical care until a catastrophic health event occurs, leading to significantly more expensive treatments, more ED visits, poorer outcomes, and long-term health problems.
  • Inadequate care received: Although medically complex patients frequently use the ED, many of their most pressing health needs often go unmet in that setting.2 In particular, many high-risk patients suffer from mental health and psychosocial concerns that ED staff are often ill-equipped to address, such as depression, substance abuse, and homelessness.

What They Did

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Description of the Innovative Activity

Care One provides intensive case management and care coordination services to the most costly (top 1 percent), medically complex patients who lack insurance. The program assigns each enrollee to a physician-led team of providers who help the patient navigate the health care system, access available financial assistance, and utilize appropriate community resources. Key elements of the program include the following:
  • Target population: All uninsured patients are enrolled in the University of New Mexico Care Program (known as UNM Care), a managed care program for indigent patients living in Bernalillo County with incomes below 235 percent of the Federal poverty level. To qualify for inclusion in the Care One program, patients must be among the costliest 1 percent of UNM Care patients. Care One leaders consider cost to be a proxy for extreme medical complexity and the associated high risk of catastrophic health events.
  • Patient identification and recruitment: Each month, the Care One medical director receives a list of the costliest 1 percent of patients. The medical director reviews the list and removes any patients who would not be appropriate for inclusion (e.g., someone who suffered a one-time traumatic event or a patient who lives outside of the county and thus does not visit the University of New Mexico for regular medical care). He then forwards the list to the Care One "shepherd," a clerk who serves as a case manager and service coordinator for Care One patients. The shepherd contacts the patients to describe the program and invite them to participate.
  • Assignment to physician-led care team: Each program participant is assigned to a care team that includes a physician/medical director (who serves as team leader), shepherd/case manager, social worker, and behavioral health specialist. Each patient also has a primary care physician, assigned on enrollment in UNM Care. The team serves as a support for the primary care physician, providing intensive case management and often taking the lead in managing the patient's care and appointments.
  • Initial patient assessment: Upon enrolling in the program, each patient meets with the entire team for an initial assessment to identify and prioritize needs, define health and life goals, and outline next steps. The team also uses the meeting to begin scheduling any necessary medical appointments with the patient's primary care physician or appropriate specialists.
  • Ongoing case management and care coordination: After the assessment meeting, the team provides each patient with ongoing case management and care coordination services. The frequency with which a patient receives services is determined by the patient's individual health needs; for example, a patient might meet with the care team weekly during a period of high medical need, whereas another patient might only receive services on a monthly basis. Services provided include the following:
    • Financial assistance: Although patients receive program services for free, many also qualify for additional financial assistance (e.g., disability payments) that can be used to access community resources outside of the University of New Mexico system. The shepherd and social worker partner to offer patients financial counseling and assist in completing and submitting requisite paperwork.
    • Appointment scheduling: The shepherd schedules, coordinates, and sends reminders for all medical appointments.
    • Counseling: The behavioral health specialist offers counseling and assistance to those patients with mental and emotional health concerns. Counseling is provided onsite at the University of New Mexico Health Sciences Center and is available on a regular or as-needed basis.
    • Medication management: A pharmacist is available onsite once a week to discuss medication consolidation and management with patients who have complex medication regimens. Patients make appointments to meet with the pharmacist as needed.
    • Community resources: The social worker helps patients access any community resources they might need, including food stamps, handicapped parking access, substance abuse programs, and other services.
  • Followup for less active patients: At regular intervals, the shepherd calls program participants who have not been in contact with the team for a period of 12 months, verifying their health status and determining whether they need ongoing services and thus should remain in the program.

Context of the Innovation

The University of New Mexico Health Sciences Center is the largest academic health complex in New Mexico, combining education, research, patient care, and community outreach. The center developed the Care One program within the context of UNM Care, a managed care program for indigent and uninsured patients. Although most patients responded well to participating in UNM Care, program leaders found that a small percentage, particularly those with complex medical and psychosocial issues, required more intensive care and care management. They decided to develop the Care One program to address the needs of these high-risk patients.

Did It Work?

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The program has significantly reduced inpatient admissions and ED visits and led to high levels of patient satisfaction.
  • Fewer inpatient admissions: An analysis of 446 patients found that the program reduced inpatient admissions by nearly 80 percent. Program participants averaged 0.14 inpatient admissions per month during the 12 months before enrollment, compared with 0.03 admissions per month during the 18 months after.
  • Fewer ED visits: ED visits among the same group of participants fell by nearly 60 percent, from an average of 0.17 visits per month during the 12 months before enrollment to 0.07 visits per month during the 18 months after.
  • Highly satisfied patients: Participants consistently provide positive feedback on program services, both on satisfaction surveys and in personal comments to members of the care team. Many patients believe the program has had a major impact on their ability to understand and manage their health and has made them more aware of resources available to them.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of inpatient admissions and emergency department (ED) visits, along with anecdotal feedback from program participants.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Assembling planning team: Key stakeholders and interested representatives from departments throughout the Health Sciences Center, including hospitals, ambulatory clinics, clinical affairs, case management, pharmacy, and the College of Nursing, assembled and met regularly to help plan the program. The team created core documents that outlined goals, priorities, and target outcomes.
  • Pilot testing of program: Program leaders received a small internal grant to launch Care One as a pilot program. Several departments within the Health Sciences Center contributed staff (typically up to one full-time equivalent) to the pilot, which began serving patients in 2004.
  • Garnering administrative buy-in: Program leaders met with Health Sciences Center administrators to build support for making the program a fully budgeted initiative throughout the institution. These leaders gathered data on the program's impact on patient outcomes and service utilization and highlighted the personal stories of patients whose lives had been positively affected during the pilot program.
  • Officially launching program: In 2005, the university committed to financing Care One, which launched as an official program of the Health Sciences Center in 2006.

Resources Used and Skills Needed

  • Staffing: Care One program staff includes four individuals: a full-time social worker, shepherd, and behavioral health specialist, along with a part-time physician/medical director. A pharmacist from within the Health Sciences Center also contributes time to the program on a weekly basis as part of his regular duties. This four-person team manages approximately 600 active Care One patients at any given time.
  • Costs: Care One operates with an annual budget of $357,878, which covers staff salaries, medical and pharmaceutical supplies, and other miscellaneous costs.
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Funding Sources

University of New Mexico Health Sciences Center
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Adoption Considerations

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Getting Started with This Innovation

  • Create guiding documents: Early in the planning process, articulate and record the program's mission, along with any core goals, intentions, and targeted outcomes. These guiding documents help program developers stay true to the original vision.
  • Identify patients in need: Be creative and vigilant in identifying medically complex patients before they suffer catastrophic health events. One strategy is to carefully scan charts to find patients requiring intensive services beyond the routine standard of care.
  • Gather data early: Collect data on patient outcomes, including utilization and anecdotal evidence of participants' functional status; this information can help the program gain traction and administrative support quickly.

Sustaining This Innovation

  • Continually collect data, including personal stories: Even if available data are minimal, continually gather and share evidence of success to maintain continued support of the program. Use personal stories to demonstrate the qualitative impact the program can have on patients' lives.
  • Maintain core group of stakeholders: Program supporters formed a "Care One Think Tank," a group of individuals passionate about championing the initiative within the community and achieving the program's goals.

More Information

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Contact the Innovator

Kathy Atencio, RN
UNM Health System
Unit Director, Care One
801 Encino NE, Suite B2
Albuquerque, NM 87106
Phone: (505) 272-4817

Innovator Disclosures

Ms. Atencio has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

More information on The University of New Mexico Health Sciences Center is available at

Forman S, Kelliher M. Status one: breakthroughs in high risk population health management. San Francisco: Jossey-Bass; 1999.


1 Lynch JP, Forman SA, Graff S, et al. High-risk population health management—achieving improved patient outcomes and near-term financial results. Am J Manag Care. 2000;6(7):781-91. [PubMed]
2 Naessens JM, Baird MA, Van Houten HK, et al. Predicting persistently high primary care use. Ann Fam Med. 2005;3(4):324-30. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 03, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 21, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 20, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
RE is a 41-year-old male who immigrated to the United States from Guatemala in 2000. He works as a ceramic tile installer and speaks only Spanish. RE first presented to the University of New Mexico emergency department in early 2005 with muscle weakness, weight loss, and a rash. After an...

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