At Stanford Coordinated Care Program (SCCP), our multidisciplinary team helps patients with chronic/complex medical conditions stabilize their health by enhancing their confidence and ability to manage their health so they can better live with their condition(s).

We utilize the Institute for Healthcare Improvement’s “Triple Aim” model to (a) improve patients' health, (b) enhance the patient experience of health care, while (c) managing or lowering the costs of medical care (for example, reduce hospitalizations and emergency room usage when possible).

Clinicians available to SCCP patients include:

• Primary care physician
• Patient care coordinator
• Behavioral health specialist (licensed clinical social worker)
• Nurse practitioner
• Clinical pharmacist
• Licensed occupational therapist
• Registered dietician

The Stanford Coordinated Care Program currently accepts direct referrals only from Stanford Medicine primary care providers. The patients we accept often struggle with persistent, serious health conditions such as (but not limited to) diabetes that is difficult to manage, heart disease, asthma/chronic lung conditions, autoimmune disorders, etc.

Yes, only the physicians and Coordinated Care team will know who is enrolled.

Each Stanford Coordinated Care patient has a care coordinator who is responsible to assist their panel of patients with their needs. Our highly trained and experienced care coordinators support SCCP patients by:

• Being the patient’s “point person” on their primary care team and communicating with the patient’s primary care provider, and other members of the SCCP care team, on the patient’s behalf;
• Identifying and planning with the patient, in achievable steps, how he or she can address and attain their individualized health goals;
• Keeping in touch with the patient between visits, by phone or MyHealth messages, to provide support or, at the patient’s request, check in regarding the patient’s progress on goals.

We accept new patients year-round.