Our Partner SNI

Complex Care Management for High Risk Patients at San Joaquin General Hospital

Complex care management for high-risk medical populations is a core component of the Public Hospitals Redesign and Incentives in Medi-Cal (PRIME) program. To address a disproportionate share of resources spent on the top 1% of beneficiaries, San Joaquin General Hospital (SJGH) implemented a new PRIME program to better care for high-risk patients, relying on data and analytics for patient identification and care coordinators to help organize care for patients with multiple conditions.

“We’ve been doing care coordination work, but PRIME is helping us move from a reactive ‘pull’ model where patients are referred individually to the program by their primary care physicians, to a proactive ‘push’ model, where we’ll be using data and predictive analytics to make sure we’ve got the right patients,” says Dr. Farhan Fadoo, Chief Medical Information Officer at San Joaquin General Hospital.

SJGH’s Complex Care Management project is overseen by the system’s recently established population health unit, and uses care coordinators who serve as a central point of contact for high-risk adult patients with four or more chronic medical conditions. The care coordinators help patients navigate the complexities of the health care system and develop strong linkages with other community resources to help address non-clinical barriers to care, such as the lack of transportation or unstable housing. As Dr. Fadoo says, “PRIME has provided a critical opportunity for us to transform the way we take care of our most vulnerable patients.”

Want more information?

Learn more about PRIME in the CAPH/SNI Issue Brief.