The California Improvement Network (CIN) and the Center for Care Innovations (CCI) hosted in Oakland a one-day regional convening on improving care for patients with complex care needs.

While much is known about how to care for patients with a single chronic condition, less is known about how to care for those with multiple physical and behavioral conditions. These patients have complex care needs, which range from medical to social. This regional convening brought together leaders from across the country who are making strides in improving the quality and cost-effectiveness of care for this population.

The convening was geared toward small teams (of two to four participants) who are leading efforts to improve care for patients with complex care needs. Priority was given to Northern California teams. Two additional convenings will be held in Southern California in the next few months.

Guest speakers addressed a variety of topics:

Identifying high-utilizing patients through risk stratification

• Clemens Hong, instructor in medicine, Massachusetts General Hospital

Patient engagement and outreach

• Rachel Davis, senior program officer, Center for Health Care Strategies, Complex Care Innovation Lab
• Maria Raven, manager of the care support program, San Francisco Health Plan and assistant clinical professor, University of California, San Francisco
• Suneel Ratan and Melissa Marshall, Community Health Center Network of Alameda County

Trauma-informed care

• Rachel Davis, senior program officer, Center for Health Care Strategies, Complex Care Innovation Lab
• Laurie Lockert, manager of the health resilience program, CareOregon

Intensive outpatient care

• Michael Kern, family medicine physician, John Muir Physician Network
• Lisa Mangiante, director, Pacific Business Group on Health
• Marcus Zachary, senior medical director, Brown and Toland Physicians

Complex care programs in the safety net

• Jason Cunningham, medical director, West County Health Centers
• Dave Moscowitz, medical director, Hope Center, Alameda Health System
• Anna Robert, acting director of care coordination for primary care, San Francisco Health Network

The policy landscape and future opportunities for health homes

• Cari Jarbouai, California State Innovation Model (CalSIM) Project

Measuring the impact of complex care interventions

• Donna Zulman, VA Palo Alto Health Care System