Ambulatory Intensive Caring Unit

The distribution of healthcare spending is strongly skewed in the United States, with the top 5% of health care spenders accounting for more than half of the total $3.2 trillion in health care spending in 2014. This high-need, high-cost (HNHC) population is often faced with multiple chronic medical and behavioral health conditions, functional limitations, and social risk factors.

Projects and Outcomes

1. Use analysis of recent health insurance claims and/or electronic health record data followed by administering the Hospital Admission Risk Multiplier Screen (HARMS-8) patient survey to invite chronically ill individuals at very high risk for costly health crises from a general population into care by a 24-7 intensive primary care team. The team includes PCPs, behavioral health clinicians, physical therapists, clinical pharmacists, and pro-active self-care coaches (care coordinator/advanced medical assistants) under close nurse practitioner or registered nurse supervision. 

2. During an initial 120-minute trust-building intake visit with a PCP and personal care coordinator, patients are aided in selecting a personally meaningful health-related goal. Each coach-supported patient is encouraged to take an initial step toward, and thus to gain the confidence needed to gradually master a progression of self-care behaviors, supported by frequent follow-up visits. The results of this approach were regularly measured via sequential administration of the Patient Activation Measure (PAM) at 6-month intervals during the first year of enrollment. Meaningful contacts with patients were 1/3 in-person, 1/3 via phone or video, and 1/3 through asynchronous secure messaging.

3. Continuously coordinate a tight network of readily accessible referral care that includes highly cost-effective physician specialists, additional behavioral healthcare providers, non-physician providers of musculoskeletal care, and social service sources on an as-needed basis. 


The AICU/IOCP model was successfully spread across 23 medical groups in 5 states via a 3 year, $19.1 million CMMI (Center for Medicare and Medicaid Innovation) grant in 2013-2015, with savings of 9% for the “top 5%” of Medicare patients across the 23 medical groups (15,000 patients).

The Stanford CERC AICU model known locally as Stanford Coordinated Care, serving Stanford University and Health Care’s self-employed “top 5%” population, achieved statistically significant reductions in hospitalizations and emergency department visits and lowered THE (total health expenditure) by 10% as compared to a propensity-matched control group in unpublished data.

Stanford Coordinated Care (SCC) also offered Team Trainings 2013-2018 to 15 medical organizations and health plans, including Intermountain Health, The Chinle Navajo Indian Medical Center, Bellin Health, Kaiser Woodland Hills, SCAN Health Plan, and several Federally Qualified Health Centers (FQHCs) and community clinics, such as those in Arkansas and Portland, OR.

Publications and News