San Francisco Health Network’s Complex Care Management Program

California

The San Francisco Health Network’s Complex Care Management Program is an integrated complex care management system in which interdisciplinary teams work with the network's 15 primary care medical homes. Patients are identified through utilization data provided by San Francisco General Hospital and San Francisco Health Plan, as well as through provider referral. The network originally provided comprehensive case management for homeless clients but now targets "high-risk, high-cost" patients in the primary care setting. The identified primary care patients keep their established primary care provider and receive additional wrap-around services from the complex care management team, including an in-home comprehensive assessment, patient centered care plan and coaching toward care plan goals. The program aims to serve 250 patients across the 15 primary care sites within the network.

Partner Organizations

• San Francisco Department of Public Health
• Medi-Cal (California Medicaid)
• San Francisco General Hospital 
• San Francisco Health Plan

Target Population

High-cost, high-need patients

Care Team

Nurse case manager, health coach, part-time social worker, coordinator (optional), part-time physician (optional)

Timeframe

2012 - present

Results/ Studies

The San Francisco Health Network's General Medicine Team (launched in 2012) has observed a 53% decrease in hospital days and an 11% decrease in ED visits after patients enroll in the complex care management program.

Funding

Private grants

Resources

Center for Care Innovations program description