Development and Implementation of an Interdisciplinary Intensive Primary Care Clinic for High-Need High-Cost Patients in a Safety Net Hospital

Paul Johnson, Mark Linzer, Nathan D. Shippee, William G Heegaard, Floyd Webb, Katherine Diaz Vickery

Research output: Contribution to journalArticle


In 2010, payment for some of Hennepin County Medical Center's highest need patients changed from fee for service to a per capita formula. This financial stress led the institution to employ a population health lens that revealed a significant concentration of spending on a small segment of the population. Finding high rates of potentially avoidable inpatient and emergency care, an organizational effort was initiated to attempt to manage this high-need, high-cost population more effectively. A freestanding interdisciplinary intensive primary care clinic was developed. Nurses led a risk stratification process to identify eligible patients for co-located medical, care coordination, and social services from multidisciplinary care teams. Workflows to engage the population were designed to reduce readmissions and inappropriate use of emergency services. Soon after opening, the clinic added mental health and substance use professionals. For people entering the clinic between January 2010 and July 2017, utilization and financial data were collected for the year before (pre) and after (post) enrollment (n = 487). Bivariate statistics and outlier analyses facilitated comparisons between pre/post enrollment. Patients visited the new clinic twice per month on average and outpatient costs almost doubled. Overall costs were 16% lower, with the largest decrease seen in inpatient costs. This experience has led to ongoing investment, replication, and expansion of the model. An interdisciplinary intensive primary care clinic for high-utilizing, underserved patients is a promising intervention. Multidisciplinary teams and ongoing institutional support are critical to program success. Payment reform is essential to the development of such programs.

Original languageEnglish (US)
Pages (from-to)124-131
Number of pages8
JournalPopulation Health Management
Issue number2
StatePublished - Apr 2020


  • Delivery system reform
  • High-cost high-needs patients
  • Intensive primary care
  • Safety net

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural

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