Care Process Redesign

Integration supports Presbyterian’s ‘Complete Care’ program

June 19, 2019 11:22 pm

Presbyterian Healthcare Services, based in Albuquerque, is a locally owned, not-for-profit health system of nine hospitals, a statewide health plan and a growing multispecialty medical group. We serve one in three New Mexicans through our healthcare services and insurance coverage.

For Presbyterian patients with serious, complex medical needs, we offer a high-touch program that combines primary, urgent and home care and is designed to improve their health and lower costs.

We started the program, Complete Care, in 2015 to focus on the 5% of Medicare Advantage patients who account for 50% of costs. Patients have access to a 24-hour phone line; primary, urgent and palliative care in their homes; and Hospital at Home services for more acute cases. Nurse case managers and social workers address other key needs.

Bringing down costs and improving the patient experience

Over the first four years, during which 1,416 home-based patients were admitted to the program, results demonstrated dramatic cost reductions combined with high patient satisfaction.

From the beginning of 2015 through the end of 2018, 16% of all home visits with Complete Care patients were urgent, and in most cases these patients subsequently avoided a visit to the emergency department (ED) or hospital. All Complete Care patients who did visit the ED or stay in the hospital received an in-home assessment within 48 hours of their discharge.

As a result of these and other interventions, the cost of care dropped 38% on a per-member, per-month basis, as compared to predicted costs for similar patients.

Patient needs guide care in the Complete Care program. Among those who died during the first four years of the program, 86% died at home, in accordance with their wishes.

In recent surveys, 98% of patients said they would recommend Complete Care.

Integrated operations pave the way to success

Integration is at the heart of Complete Care’s success.

Without readily available health plan data, it would have been impossible to determine which patients would most benefit from the program or to accurately track their progress. 

In addition, because we accept full risk for the Complete Care population, we have the flexibility to fine-tune the program and to fund interventions that are not considered in a fee-for-service environment.

The program also builds on the expertise of an interdisciplinary clinical team that serves our Hospital at Home and House Calls programs and that provides palliative care in clinic and home settings. Complete Care began as a home-based program and expanded in 2018 to include an outpatient clinic. Services in both settings are available to health plan members who meet certain medical criteria.

Finding new ways to help high-risk patients

Complete Care patients face many challenges. All have functional decline and are at risk of needing long-term institutional care. Many have social needs such as unstable housing, lack of transportation or an inadequate supply of healthy food.

These needs, too, are considered by the care teams. For example, care coordinators can “prescribe” healthy food for Complete Care patients at Presbyterian’s Food Farmacy, which on a weekly basis provides free fresh produce and shelf-stable items like oatmeal and tuna for patients in need.

One patient had uncontrolled diabetes and very limited vision, was not taking medications as prescribed and had visited the ED seven times in the year before he joined Complete Care in 2017. Since then, he has not returned to the ED. He has dramatically improved glycemic control and been weaned off most of his sedative medications.

Thanks to the interventions of his social worker and care coordinator, he has a functioning cooling system in his home. And, with his diabetes under control, he was able to take his first vacation in years.

For integrated systems with expertise in high-need populations, the type of wraparound approach seen in Complete Care provides patients with the help they need when they need it, and at a lower cost.


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