Virginia Commonwealth University Medical Center's Complex Care Clinic

Virginia

Virginia Commonwealth University's Coordinated Care program established the Complex Care Clinic (CCC) in 2011 to improve quality of care and decrease costs for high-need patients with financial, social and other barriers to accessing needed care. CCC uses the Camden Coalition's hotspotting technique to identify where complex patients live, as well as coldspotting to identify areas that lack social services in order to identify the highest need areas within the Richmond Metropolitan Area for intervention. Using this technique, Richmond's East End was identified as an especially high-need area, and is now the focus of the TakeCCare initiative, which uses community outreach workers to conduct home visits, accompany patients to medical appointments to aid self-management and reinforce care plans, connect patient to community services to address unmet social needs, and identify other issues that may affect health outcomes. The outreach workers communicate regularly with other members of the interdisciplinary care team to coordinate care. The CCC is part of Robert Wood Johnson Foundation's Transforming Complex Care initiative. 

Partner Organizations

• Virginia Commonwealth University Health System
• Peter Paul Development Center
• YMCA
• The Daily Planet
• Richmond Behavioral Health Authority
• Robert Wood Johnson Foundation

Target Population

Uninsured patients with six or more chronic conditions who are ER super-utilizers

Care Team

Physician, nurse practitioner, social worker, clinical pharmacy fellow, pharmacist, clinical nurse, RN case manager, medical outreach worker

Timeframe

2012 - present 

Results/ Studies

Overview and results (2016 presentation)

VCU Medical Center Annual Report (2013)

Funding

Virginia's Indigent Care Program

Resources

Program website

Profile by the Center for Health Care Strategies, Inc. (October 2017)

Webinar: Approaches to Extending Complex Care Models into the Community: Emerging Evidence (August 2018)