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  • Review the limitations of “one-on-one” model of care for socially complex, chronically ill patients who are frequently admitted to the hospital.

  • Describe the key components of interdisciplinary models of care for high-risk patients

  • Review case studies of interdisciplinary programs for high-risk patients.


Five percent of patients account for 50% of health-care costs.1,2 These patients are often poor and have high rates of chronic disease, mental illness, and/or addiction.2,3 Even when health-care services are readily available, many patients face multiple barriers to effective care such as homelessness,4 low literacy,5 social isolation,6 language barriers,7 addiction,8 and mental illness.9 These barriers to health care result in high rates of emergency department care and hospitalization, which drive the high costs of care in this population.1,2

There are many interdisciplinary models of care in the United States that have successfully decreased utilization and cost for patients at high risk for frequent hospitalization. They all include interdisciplinary teams in which both medical and nonmedical professions partner together to improve care for patients. Team members may include physicians, nurses, nurse practitioners, social workers, physical and occupational therapists, community health workers, health educators, pharmacists, psychologists, and other health professionals. These teams proactively identify the highest risk patients, create an interdisciplinary care plan that includes care coordination, and monitor how each patient is meeting the care plan goals.1 These innovative, interdisciplinary models of care improve outcomes and costs by helping patients overcome personal vulnerabilities as well as social and health system barriers to effective care.2

This chapter discusses the concepts underlying these interdisciplinary models of care for high-risk patients, and describes specific programs. While the concept of providing interdisciplinary care for high-risk patients underlies all of these models of care, the different ­models may use different words to describe their work. Case management, complex care management, ambulatory intensive care units (ICUs), and care coordination are all terms that individual programs use to describe their work improving outcomes for high-risk populations using interdisciplinary teams. Throughout this chapter, we use “interdisciplinary models of care” to describe all of these types of programs. However, in each case ­example, we use the particular words that each program uses to describe itself.


Mr. Beltran is a 56-year-old man who works as a day laborer but is unable to find a steady job. Living in homeless shelters, he becomes increasingly depressed, and begins to drink heavily. After visiting the emergency room and being diagnosed with diabetes, he is referred to the resident clinic at the county hospital. Here he has difficulty attending scheduled appointments with his primary care provider because of his unpredictable work schedule and his alcohol addiction, so he drops into clinic only when he is sick. In these visits, ...

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