Wisconsin: Improving complex disease management through multi-specialty care teams

ThedaCare, a Wisconsin-based accountable care organization (ACO), is piloting a team-based care model for improved management of their most complex, high-risk patients, including those with diabetes. The Complex Patient Care Model Redesign aims to dramatically improve quality and cost of care as well as patient and physician experience through a more robust, holistic approach to health that integrates all aspects of patient care. Multispecialty teams include clinical pharmacists and behaviorists in addition to physicians, nurses, advanced practice clinicians, and care coordinators. The program focuses on improving care coordination and navigation, patient engagement, mental health recognition and management, community resource connection, environmental and socioeconomic barriers, and medication management. The team-based care model is intended for patients at high risk being in the top 5% of spending, as identified through a risk stratification tool. A comprehensive intake visit introduces patients to the program and the multidisciplinary care team. The team develops a patient care plan, which is updated and revised regularly. In addition to regular patient contact, the team utilizes new technology like remote bariatric monitoring to assist patients in managing their condition between office visits.

Because fee-for-service payment provides very limited support for the team-based care model, it is currently supported by a grant, with the pilot being used to provide a better assessment of its impact on cost and thus the extent of payment reform needed to sustain it. Currently, the ACO shares in savings or losses in care costs above certain benchmarks but the ThedaCare leadership believes that more significant payment shifts toward partial or full capitation would be helpful for sustainability. 

Approximately 1800 patients have been identified as high-risk in the pilot sites, 54% of whom are diagnosed with diabetes. So far, during the initial pilot phase, almost 100 of these patients have been enrolled in the program. While the Complex Patient Care Model Redesign is a new program, it builds from numerous successful strategies employed by the ACO in the past, and limited early results look promising.