Designs Formed in Fellowship Program

Since the 1950s, annual growth in health care expenditures in the United States has exceeded GDP growth by two to three percentage points. CERC is the only university-based research center in the U.S. exclusively dedicated to identifying and demonstrating care delivery innovations to safely close this growth gap.

The resulting innovative CERC “care models” combine scalable cost-effective methods of care delivery that CERC teams uncover globally and domestically with features from emerging science and technology. To accelerate their adoption, CERC also embeds features that address the most deeply felt unmet human needs of patients, families, and their clinicians.

Progress to Date

Since its inception three years ago, seven new CERC care models carrying the potential to reduce annual U.S. health spending by > $300 billion have been developed and selected for pilot testing by twenty clinical teams across the United States. 

These care models have yet to be tested.

Our 2016-17 Prescription Medication Team at Pharmac in New Zealand

Late-Stage Cancer Care

In addition to premature death, patients with late-stage cancer suffer considerable disability and pain. The annual cost of cancer care exceeded $124 billion in the United States in 2010 and is expected to increase to $173 billion by 2020—a rate that outpaces the projected growth of overall medical expenditures. Much of these expenditures are expected to occur for late-stage cancers, defined as cancers with a very poor prognosis due to type or stage.

Opportunities for savings

A conservative estimate of net savings from national implementation of the CERC model is $37 billion dollars in direct U.S. healthcare spending per year.

Safely reducing annual per capita spending for late-stage cancer care

The key elements of the model include:

  1. Help patients and their caregivers better formulate their goals for care and select treatment options that will better meet their goals
  2. Offer immediate treatment of pain and other symptoms associated with late-stage cancer at home through a 7/24 call center, staffed by nurses specializing in cancer care using symptom treatment algorithms and pre-placed emergency medication packets in patients’ homes
  3. Provide chemotherapy mostly in the patient’s home, or safe, economical sites closer to patients’ homes

Chronic Kidney Disease Care

People with chronic kidney disease (CKD) have high rates of hospitalization and cardiovascular events, disability, and premature death. 1% of CKD patients have severe, non-reversible kidney damage (end-stage renal disease—ESRD). Americans with CKD incur roughly $315 billion in annual health spending and account for almost a quarter of Medicare spending—over $121 billion annually. Patients who progress to ESRD incur health spending in excess of $87,000 per person per year.

Opportunities for savings

Our estimate of net savings from national implementation of the CERC CKD model is $63 billion dollars in direct healthcare spending per year—20% of the estimated $315 billion spent each year on CKD by public and private payers.

Safely reducing annual per capita CKD care spending

The key elements of the model include:

  1. More proactive identification and treatment of patients with early-stage CKD to slow disease progression and its high costs
  2. Cost-efficient coordination of care for patients approaching ESRD to prevent costly, unnecessary hospitalization and emergency room visits and to establish the least hazardous form of vascular access for those patients who prefer hemo-dialysis to treat end-stage disease
  3. Assuring that patients have an opportunity to select a treatment for ESRD that best fits their personal preferences. This includes the opportunity to select home-based treatment options such as overnight peritoneal dialysis, which are much less costly and physically exhausting than care in dialysis centers.

Stroke Prevention and Care

Ischemic cerebrovascular disease (CVD) is a leading cause of disability in the United States. CVD causes almost 700,000 strokes annually, as well as other significant complications including dementia and transient ischemic attacks (TIA). In 2014 roughly $48 billion will be spent in the U.S. to prevent CVD and other cardiovascular diseases and to treat strokes.

Opportunities for savings

A conservative estimate of national savings from full implementation of the CERC model is $2.8 billion dollars in direct healthcare spending per year, or 6% of annual spending for treatment of cerebrovascular disease.

Safely reducing annual per capita stroke spending

The key elements of the model include:

  1. The usage of nurse-led teams to increase patient use of protective medications from 60% to >85% to prevent stroke and thereby avoid downstream costs resulting from hospital care, rehabilitation/nursing home care, and direct healthcare costs related to stroke disability
  2. The replacement of hospitalization with home-based care for most patients who have experienced a transient or mild stroke, following a brief evaluation in a hospital emergency department
  3. The application of a rapid treatment protocol to reduce the delay in the usage of clot-dissolving medication by 50 minutes for patients with severe strokes, as these patients lose an estimated 1.9 million brain cells for every minute of treatment delay

Pediatric Chronic Illness Transition Care

Due to the success of Neonatal Intensive Care Units (NICUs), childhood cancer treatment, and organ transplantation technology, a growing population of young people with complex chronic disease are now surviving into adulthood. It is estimated that they will soon comprise in excess of 10% of young adults, compared to approximately 1% of young adults prior to these advances in childhood care. When pediatric patients with complex disease transfer to adult care, the triple threat of serious disease, immature executive judgment, and loss of usual care sources cause surges in preventable disability, hospitalization, and health spending.

Opportunities for savings

A conservative estimate of cost savings from national implementation of the CERC transitions model is $200 million dollars in direct healthcare spending per year. Annual savings are likely to grow as more and more children with complex chronic illness survive into adulthood.

Safely reducing annual spending for young patients with complex chronic illness transitioning to adult care

The key elements of the model include:

  1. For patients and their caregivers, development of the knowledge, beliefs, and skills to successfully self-manage their illness in a less-nurturing adult care system
  2. Provision of close support for a safe on-boarding in the adult care system
  3. The establishment of tele-mediated connections between patients’ prior pediatric specialty providers and the patients’ new adult care providers, who are often unfamiliar with severe childhood-acquired illnesses. Providing a smooth transfer helps families avoid unnecessary worsening of disease (e.g. transplant organ rejection) and the concomitant costs associated with emergency room use and hospitalization.

Ambulatory Surgical Care

Ambulatory surgical care currently accounts for $209 billion, or 8% of domestic healthcare spending. It is a sector that is experiencing one of the fastest rates of growth, and there are significant opportunities to reduce costs and improve patient experience.

Opportunities for savings

A conservative estimate of national savings from full implementation of the CERC surgical model is $45 billion per year in direct healthcare spending by the end of year five, or 21% of annual domestic spending on outpatient surgical care.

Safely reducing annual per capita spending for ambulatory surgery

The key elements of the model include:

  1. Reduction of the volume of surgeries, targeting overuse, through the routine use of patient decision aids, provider clinical decision support, and primary care provider case coaching
  2. Resetting the location of the majority of elective ambulatory surgery to free-standing ambulatory surgical centers operating with expanded hours (18 hours a day/7 days a week)
  3. Standardizing processes through the implementation of coordinated transitions, homogenized inputs, and streamlined operations

Spine Pain Care

In 2005, the national expenditure for back and neck pain (spine pain) approached $86 billion. Meanwhile, patients with spine pain reported worse physical and social function, mental health, and ability to work than a decade prior, when spending was nearly 40% lower. Over the same time period, the prevalence of disability attributed to musculoskeletal pain—of which back pain contributed a large portion—rose from 20 to 25%, alongside an alarming 16,000 annual deaths related to overdose of prescription opioid medications. In brief, over the last few decades, we are spending more and getting much less.  Because the status quo follows an unsustainable trajectory, we sought to identify a higher-value method of care delivery that lowers national healthcare spending and improves outcomes for patients with spine pain.

Opportunities for savings

Conservative forecasts show the ICE Model could result in a net reduction in per-capita spending for spine pain by 25%, or $21.5B in direct care costs. Taking into account lost productivity, savings could grow to over $70B annually.

Safely reducing annual per capita spine pain spending

The key elements of the model include:

  1. The immediate triage of patients at low risk of chronic spine pain into conservative care to prevent overtreatment of self-limited pain
  2. The administration of customized care for patients at high risk of chronic spine pain into a high-touch care pathway that addresses both physical and psychosocial risk factors
  3. The enhancement of decisions for patients and providers via shared decision making tools for preference-sensitive procedures and decision support aids during physician order entry

Critical Care

For years, the intensive care unit (ICU) has been a successful and efficient method to care for the critically ill. The patients best suited for the ICU have acute, reversible critical illnesses. However, 40% of the current patients in ICUs  may be "too well" to benefit from critical care. These patients may require more intensive monitoring than the typical hospital floor provides but are not in need of active ICU treatments. At the same time, millions of patients are seen in ICUs who are "too sick" to benefit from critical care. Indeed, such care may be inconsistent with their values and expressed wishes. We set out to design a model of ICU care delivery that would appropriately address the needs of these diverse patient populations while reducing the overall costs associated with ICU care.

Opportunities for savings

A conservative estimate of national savings from full implementation of the CERC critical care model is 20% in direct healthcare spending for intensive care delivery through a reduction in ICU admissions and length of stay.

Safely reducing annual per capita spending

The key elements of the model include:

  1. The installation of contactless monitors on all non-ICU beds in order to detect clinical instability earlier than existing methods
  2. The development of a mobile surveillance team to intervene earlier than rapid response teams for deteriorating patients, to monitor patients with high labor needs, and to improve transitions of care for patients entering and leaving the ICU
  3. The proactive addressing of goals of care upstream of the ICU to prevent patients from being admitted to the ICU and to prevent ICU/hospital readmissions

Colorectal Cancer Screening

Colorectal cancer is the fourth leading cause of cancer. 80 million people need screening for the disease, but nearly 32 million of these have not been screened even though screening has been shown to reduce the incidence and mortality associated with colon cancer.

Opportunities for savings

A conservative estimate of net savings from national implementation of the CERC model is $3.6 billion per year.

Safely reducing annual per capita spending

The key elements of the model include:

  1. Using locally available data to identify patients due for screening
  2. Lowering screening costs and improving compliance by offering effective, non-invasive FIT screening via shared decision-making and best-practice colonoscopy process
  3. Ensuring completion of the screening process, and any necessary re-screening, via a tele-enabled closed loop control system

 

Obesity

Severe obesity is an increasingly prevalent condition with costly associated co-morbidities that account for 10% of total annual healthcare spending in the United States.

Opportunities for savings

A conservative estimate of net savings from national implementation of the CERC model is $38 billion.

Safely reducing annual per capita spending

The key elements of the model include:

  1. Improving the probability of successful treatment through risk assessment and selective use of psychotherapy
  2. Creating individually tailored weight loss plans using low-cost health coaches
  3. Engaging participants in long-term (two to three years) stepped-care using low-cost information technologies

Pilot Test Site Map

The map below shows the locations of CERC's Demonstration Projects as of November 2015.

List of CERC Pilot Test Sites

Location Partner Model
Allina Health St. Paul and Minneapolis, Minnesota Chronic Kidney Disease
CareMore Cerritos, California Cancer Care
Geisinger Health System Danville, Pennsylvania Stroke Care
Intermountain Healthcare Salt Lake City, Utah Pediatric Transitions
Mount Sinai Hospital New York City, New York Chronic Kidney Disease
Oregon Health & Science University Portland, Oregon Spine Pain
OSF Saint Francis Medical Center Peoria, Illinois Pediatric Transitions
St. Jude Heritage Medical Group Brea, California Cancer Care
Stanford Children's Health Palo Alto, California Pediatric Transitions
Stanford Health Care Palo Alto, California Stroke Care
Stanford Health Care Palo Alto, California Surgical Care
Unite Here Health Chicago, Illinois Cancer Care
Unite Here Health Atlantic City, New Jersey Cancer Care
VA/PAHCS Palo Alto, California Cancer Care
VA/PAHCS Palo Alto, California Chronic Kidney Disease
Virginia Mason Seattle, Washington Stroke Care

CERC Design Fellowship Alumni

The CERC fellowship has been able to attract individuals from across the nation. While some fellows have continued on at CERC and Stanford, others have taken their experiences to start their own businesses, or continue to lead and innovate elsewhere.

 

Alumni Name Year Care Model Current Position
David Moore, PhD  2011-2012    Chronic Kidney  Disease Care / Late-Stage Cancer Healthcare Delivery Innovation Engineer, Operations Research and Management Science Consultant at Careflow Logic
Graham Abra, MD  2011-2012    Chronic Kidney Disease Care / Late-Stage Cancer Clinical Assistant Professor, Nephrology, Stanford University School of Medicine. Medical Director at WellBound San Jose, and Medical Clinical Affairs Director at Satellite Healthcare.
Kimberly Stone, MD  2011-2012  Implementation Fellow Clinical Instructor, Department of Surgery, University of California San Francisco
Manali Patel, MD, MPH  2011-2012  Chronic Kidney Disease Care / Late-Stage Cancer Assistant Professor of Medicine for Oncology, Stanford University School of Medicine, Palo Alto Veterans Affairs Health Care System.
Sarah Adler, PhD  2011-2012  Implementation Fellow Clinical Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Stanford. Co-founded Cross-Sectional Consulting with Dr. Sundeep Singh and Founder of a Group Practice delivering evidence based psychotherapy
Sundeep Singh, MD  2011-2012  Implementation Fellow Clinical Assistant Professor, Gastroenterology & Hepatology, Stanford University School of Medicine
Dana Steidtmann, PhD  2012-2013  Pediatric Chronic Illness Transitions to Adult Care Founding partner of Peninsula Behavioral Health. Senior Instructor at University of Colorado-Denver Anschutz Medical Campus.
Jared Conley, MD, PhD  2012-2013  Stroke Care Clinical Fellow, Emergency Medicine, Harvard (MGH/BWH)
Rachel Bensen, MD, MPH  2012-2013  Pediatric Chronic Illness Transitions to Adult Care Clinical Assistant Professor, Pediatric Gastroenterology, Stanford University School of Medicine
Waimei (Amy) Tai, MD  2012-2013  Stroke Care Vascular Neurologist at Christiana Care Health System. Reviewer for the American Heart Association and Journal of Neurologic Disorders and Journal of Clinical Case Reports.
Yana Vaks, MD  2012-2013  Pediatric Chronic Illness Transitions to Adult Care Pediatric Critical Care Physician, Kaiser Permanente. Co-Founder of Society of Aspiring Minority Physician Leaders.
Feryal Erhun, PhD, MS  2013-2014    Ambulatory Surgical Care Associate Professor, Cambridge Judge Business School, UK
Kim Brayton, MD, MS  2013-2014  Ambulatory Surgical Care Practicing Cardiologist at Fountaingrove Cardiology
Maziyar Kalani, MD  2013-2014  Ambulatory Surgical Care Spine Surgery Fellow, Cleveland Clinic
Roya Saffary, MD  2013-2014  Implementation Fellow Clinical Instructor, Anesthesiology and Perioperative Pain, Stanford University School of Medicine
Arthur Wood, MD  2014-2015  Spine Pain Care Medical Director, Pain Consultation Clinic at Zuckerberg San Francisco General Hospital and Trauma Center
Jeffrey Jopling, MD  2014-2015  Critical Care General Surgery Resident, Stanford University
Kelly Vranas, MD  2014-2015  Critical Care Assistant Professor of Medicine, Pulmonary and Critical Care, Oregon Health and Science University
Lawrence Huan, MD  2014-2015  Spine Pain Care Managing Director, Clinical R&D at Evolent Health. Practicing Urgent Care physician at Palo Alto Medical Foundation
Meghan Ramsey, MD  2014-2015  Critical Care Clinical Assistant Professor, Stanford Medicine Pulmonary & Critical Care Medicine. Interventional Pulmonology Program Director, Stanford Cancer Center South Bay
Sierra Matula, MD, MSHS  2014-2015  Spine Pain Care Practicing Surgeon for UCSF Medical Center
Adam Miner, PsyD  2015-2016  Oncology Care Instructor, Stanford Psychiatry and Behavioral Sciences
Eugene Hsu, MD, MBA  2015-2016    Implementation Fellow Adjunct Lecturer, Stanford Medicine Primary Care and Population Health.  Anesthesiologist at the Palo Alto Medical Foundation.
Ian Goldstein, MD, MPH  2015-2016  Oncology Care Consultant at The Boston Consulting Group
Jody Lin, MD  2015-2016  Early Childhood Pediatric Care Clinical Instructor, Pediatrics, Stanford University
Julie Lawrence, MS, MBA  2015-2016  Oncology Care Program Officer, Gordon and Betty Moore Foundation
Maysa De Sousa, PhD, MS  2015-2016  Early Childhood Pediatric Care Assistant Professor of Psychology at Springfield College
Tiffany Lundeen, MA, MSN  2015-2016  Maternity Care Practicing Midwife and Researcher at UCSF's Maternal and Newborn Health Research Cooperative
Victoria Woo, MD  2015-2016  Maternity Care Chief Resident in Obstetrics and Gynecology, Kaiser Oakland Medical Center.
Brian Brady, MD  2016-2017  Prescription Medication Stanford CERC second year research fellow. Nephrology Fellow, Stanford
Cliff Sheckter, MD  2016-2017  Dementia Care 5th year Resident Plastic & Reconstructive Surgery at Stanford
Daniel Yang, MD  2016-2017  Dementia Care Patient Care Fellow in Diagnostic Excellence, ‎Gordon and Betty Moore Foundation.
Nick Bott, PsyD  2016-2017  Dementia Care Stanford CERC second year research fellow. Neuropsychology Fellow at Stanford School of Medicine, Affiliated with NueroTrack Technologies.
Scooter Plowman, MD, MBA, MS  2016-2017  Prescription Medication Director of Clinical Solutions at Proteus Digital Health
Stephanie Peters, MS, PsyD  2016-2017  Prescription Medication Founder and owner of Peters Psychological Services, LLC