Integrated Inpatient/Outpatient Care for Patients at High Risk of Hospitalization

Program Location: 
Chicago, IL
Payer Type: 
Partner Organizations: 
University of Chicago

In July 2012, the University of Chicago received a Health Care Innovation Award to test a model of care delivery that reasserts the importance of an ongoing doctor-patient relationship. The project will use multidisciplinary teams - including registered nurses, licensed practical nurses, social workers, and medical assistants led by comprehensive care physicians (CCPs) - to provide consistent care to Medicare beneficiaries before, during, and after hospitalizations. CCPs will perform rounds in hospitals 48 weeks per year, ensuring they see patients and monitor their health consistently. The targeted population will include beneficiaries with a high probability of hospitalization, making it more likely that CCPs will encounter their patients during rounds in the hospital.

Over a three-year period, this program will train an estimated 26 workers and will create an estimated 11 jobs. The new workers will include a programmer, 4 research assistants, 5 comprehensive care physicians, 2 nurses, a social worker and a medical office assistant.  This program estimates savings of $18.75M over a three year period.

Payment Model: 

This program is funded with a $6.1 million grant.

Last updated April 2014
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