Community Care Outcomes

Cleveland Clinic’s Community Care brings together functions that partner to provide exceptional care that is personalized, equitable, and accessible for patients and the communities served. These functions are built on a foundation of engaged caregivers who are guided by transformative research and education. As a multidisciplinary and multifunctional care team, Community Care’s operations are across 20 family health centers, 8 regional hospitals, and 60 regional primary care practices, caring for communities across Northeast Ohio.

Community Care's Clinical Operations include departments that provide coordinated care across the practices of adult and pediatric primary care, consultative internal medicine, geriatrics, hospital medicine, medical care at home, clinical genomics, functional medicine, and wellness and preventative medicine. These teams serve patients during their lifetime and reach across multiple venues to provide continuity throughout the continuum of care.

Community Care's Value-Based Operations team is designed to encourage the patient- and caregiver-centered team care model through multidisciplinary collaboration. Their scope is to support the empaneled patients of the primary care teams. Using data to target improvement and patient engagement, these care teams focus on optimizing patient outcomes, quality, and cost through proactive management of a patient's health, wellness, and chronic diseases.

The Community Health & Partnerships team works to bridge clinical efforts with community needs by leveraging internal capabilities and engaging community partners to assist with removing barriers to care, which often include social needs. Social needs are nonmedical aspects of individual and family lives that can affect one's ability to maintain health and well-being. These could include housing (stability and quality), food (stability and security), as well as legal needs related to immigration status, eligibility for public health insurance, employment, family/housing access, and government benefits access for income maximization.

The capabilities in Clinical Operations, Value-Based Operations, and Community Health & Partnerships are synchronously deployed to enable excellent and focused longitudinal care for patients and communities.

Key programs include the following:

• Center for Geriatric Medicine, ranked 2nd as one of the nation’s top geriatric centers by U.S. News & World Report
• Center for Value-Based Care Research, aimed at studying new models of healthcare
• Primary Care Women’s Health program for gender-specific care, education, and research
• Medicare Accountable Care Organization (ACO), which currently manages a population of 85,000 patients across Northeast Ohio and is one of the largest in the country
• The Executive Health program, which combines world-class health care and wellness services to provide the most comprehensive, tailored, streamlined executive health physical examination available. This approach transforms the traditional physical examination into an integrated, personalized, head-to-toe evaluation. This service is offered in Cleveland, Florida, Abu Dhabi, London, and Toronto. Combined, the programs have relationships with more than 500 companies, and more than 7000 patients are seen annually
• Ambulatory Care Management, which consists of 4 key members of the care team, including Primary Care Coordination, Primary Care Social Work, Population Health Navigation, and the RN Contracting Team
• The inSight Community Monitoring Program, developed to ensure the proactive management of at-risk populations in the midst of the COVID-19 pandemic. This includes patients who test positive for or are suspected of having COVID-19, patients with chronic diseases who are considered high risk, and patients recently discharged from the hospital
• Transitional Care Management Home Visit program, which consists of a series of postdischarge in-home visits with Advanced Practice Nurses and Community Paramedics from the Medical Care at Home team for patients with a high risk of readmission
• Virtualist Program, which consists of providers who utilize telehealth tools/technologies to reduce inappropriate emergency department and inpatient utilization and safely navigate patients to the appropriate levels of care. Target support areas for second level triage/deescalation include patients identified as needing emergency services from Nurse-on-Call, Family Health Centers, Express Care, Home Health, and the inSight Community Monitoring Program
• Additional Medical Neighborhoods formed in partnership with specialty colleagues to support seamless patient care, including Peripheral Artery Disease and Sickle Cell Disease in addition to established Heart Failure, Chronic Kidney Disease, and COPD
• Program initiated to increase the testing of lead in children with the implementation of a new in office capillary lead test with supporting EMR functions
• Launched Home Care + to provide patients with high intensity home-based rehabilitation with standard nursing visits and optional custodial care
• Established partnership program with United Way where navigation services were provided at 5 Express Care sites to serve patients’ social needs
• Home Monitoring Program offered to COVID-19 patients, which involved technology-driven check-ins along with caregiver phone calls for specific patient populations
• Genetic counseling services provided to pediatric and adult patients
• Focused on patient and caregiver wellness through lifestyle, integrative, and functional medicine services