Project Feature

Sutter Health

A Center for Medicare Medicaid Innovation

Spread and matured a home-based care management program that systematically aligns care with the needs, values, and preferences of persons with advanced illness. Developed and nurtured the care teams to support patients’ physical, mental, and spiritual needs.


Purpose:  Improve quality of life and mitigate avoidable crisis care by hardwiring program interventions and bridging the gaps between the hospital, physician’s office, and the home.

  • Promote shared decision making based on disease trajectory and goals of care
  • Ensure proper medication management
  • Create awareness of red flag symptoms and teach self-management skills
  • Encourage proper follow-up care
  • Keep medical team in the loop of patient’s health status and needs

Activities:  Each of the following activities represent distinct projects to support program development, spread and sustainability.

  • Launch startup operations and scale the program from a pilot to 14 teams serving patients across 19 counties in Northern California
  • Strengthen oversight, enable tighter care coordination and real-time performance management by directing the build of a robust data analytics infrastructure
  • Create and implement role-based orientation roadmaps/ toolkits and a comprehensive education program founded on five evidence-based pillars.
  • Strengthened care management around the clock by building an afterhours RN Telephone Triage service, including the creation of triage protocols, workflows, and escalation procedures.

Outcomes: Over the course of this three-year project, the program:

  • Improved quality of life for nearly 10,000 patients who achieved greater stability and endured fewer crises.
  • Overall patient/family satisfaction rating of 96%
  • Reduced hospitalization by 58% and ICU visits by 72%,
  • Saved payers $91M (triple the 3-year CMMI grant target).


Link to an article about the program:

Sutter Health

Center for Integrated Care

Co-developed a suite of 33 health literate stoplight tools for disease and condition self-management.

PURPOSE:  Empower patients as they learn to self-manage and make decisions about when to seek care.   Design to function as “quick start guides” for patients who have been asked to conduct daily health assessments related to a variety of topics, including:

  • Oncology medications
  • Surgical procedures
  • Chronic illness management


  • Conduct patient focus groups and consult with clinical content experts to identify key themes relevant to each topic (condition, symptom, or medication).
  • Partner with graphic design experts to develop a health literate format to promote visual consistency across topics.
  • Manage field-testing in clinical settings, conduct quantitative and qualitative evaluation and lead the iterative editing process for all English versions.
  • Manage translation of the tools into 10 languages. This collaborative process included coordinating with a certified vendor to translate, field test and edit each translated version with native-speaking patients and clinicians to ensure ease of understanding and cultural competency.

OUTCOMES: Patients use the tools at home to identify and manage early signs and symptoms, often preventing a crisis and the need for crisis care. The tool guides the level of care needed as self-identified pain and symptoms escalate.

AWARDS:  Received two awards for our plain language work on the Stoplight Tools:

  • Center for Plain Language - ClearMark Award of Distinction
  • Sutter Health Presidents’ Award

Given their reported success at helping patients know when to seek help, reducing utilization and improving condition self-management, Sutter Health made the tools available for use system wide across its 24 hospitals, primary care, home care, palliative and hospice service lines. Sutter has made the tools available for purchase by health systems nationwide.

Helping Patients Manage Complex Health Issues

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