Clinically Fragile Patients with Chronic Disease



  1. Use analysis of recent health insurance claims and/or electronic health record data followed by a Patient Activation Measure (PAM) survey to invite chronically individuals at very high risk for costly health crises from a general population into care by a 24-7 primary care team that includes PCPs, behavioral health clinician(s), and self-care coaches with NP or RN supervision

  2. During an initial 120 min trust-building intake visit with a PCP and personal self-care coach, help each patient to select a personally meaningful health-related goal and an initial step toward a progression of self-care behaviors for each coach - supported patient to gradually master with proactive follow-up by each patient’s personal self-care coach.

  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.

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