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Journal Article


Predictive Modeling and Team Care for High-Need Patients at HealthCare Partners

The Issue

The cost of care for the 5 percent of the U.S. population with the greatest health care needs accounts for half of all health care spending. Improving the quality of care for these patients would not only improve outcomes, but also would generate savings that could be used to increase access and services for other patients.

The Innovation

HealthCare Partners Medical Group, one of the nation's largest physician groups, opened five comprehensive care centers where multidisciplinary teams composed of physicians, nurse care managers, and social workers work intensively with patients over a six-week period to stabilize them and reduce the risk of hospitalization. The group also sends provider teams to homebound patients to provide a similar service.


For patients in the high-risk program, hospital use has declined 20 percent over the two years of the program, saving the system $2 million annually for every 1,000 members.

Publication Details



J. L. Feder, "Predictive Modeling and Team Care for High-Need Patients at HealthCare Partners," Health Affairs, March 2011 30(3):416–18.