Alameda Health System

California

As part of their Delivery System Reform Incentive Program, Alameda Health System (AHS) established a complex care management program for its highest utilizers. The program - called the Hope Center - uses multidisciplinary care management focused on social stabilization, care coordination and behavioral health. The Hope Center includes two pathways, both of which differ from regular primary care. Patients who do not currently have a primary care provider receive these services through the Hope Center in addition to care management (“primary care embedded”). Patients who are already receive primary care within AHS retain their provider, and the Hope Center provides care management services in close collaboration with that provider (“primary care linked”). In 2016, Alameda Health and Sutter Health partnered to launch the PreManage ED system, which alerts six area hospitals whenever a frequent utilizer is admitted at any one location.  The system provides each targeted patient with a portable health record and care plan. 

Partner Organizations

• Alameda Health System 
• Local Federally Qualified Health Centers
• Sutter Health
• Better Health East Bay
• California Healthcare Foundation
• Alta Bates Summit Medical Center in Oakland and Berkeley
• Sutter Delta Medical Center in Antioch
• Eden Medical Center in Castro Valley
• Highland Hospital in Oakland
• San Leandro Hospital in San Leandro

Target Population

High-risk, high- cost patients with 3+ admissions in 1 year

Care Team

Physician, medical assistant, community health worker, social worker and two nurse care managers with consultation  from a pharmacist and psychiatrist trained in addiction medicine

Timeframe

2013 - present

Results/ Studies

N/A

Funding

Private grants and philanthropic donations

Resources

Center for Care Innovations program description 

PreManage ED system description

2016 post by Kristen M.J. Azar on LinkedIn