When faced with the fact that just 5 percent of the patient population was responsible for nearly half the money it spent on healthcare each year, Utah’s Intermountain Healthcare decided to make some radical changes to keep these most vulnerable patients from falling through the cracks.

Intermountain leaders knew that primary care doctors are up against a universal influx in patient volume and could not set aside enough time and attention to treat the multiple chronic conditions – physical, social and psychological – presented by this most at-risk group. And hospitals were unable to offer these patients personalized, cost-efficient care.

This is not a challenge unique to Salt Lake City, of course.

"We need to acknowledge that most of us don’t spend our lives sitting in a doctor’s office. Most of us spend our lives at home in our communities," said Wendy Wolf, MD, CEO of the Maine Health Access Foundation. "And when people leave the hospital, when they leave the doctor’s office, they have to go home and figure out, ‘How the heck do I do what they just told me I need to do.’”

All the while, readmissions have been racking up alongside costs across the industry, and patients often go home frustrated.

[See also: Intermountain signs sweeping EHR deal.]

At the behest of affected patients and providers alike, Intermountain created a Personalized Care Clinic, an initiative already starting to show positive outcomes, according to Tim Johnson, MD, medical director of the Intermountain Medical Group, and David Henricksen, regional assistant operations officer of Intermountain Health.

The PCC has the look of a patient-centered medical home, Johnson explained, but the services it offers for a specific patient demographic facing complex, ongoing medical issues is what sets it apart.

The team, which is ever-expanding, includes the following professional types: two internal medicine physicians, a part-time palliative care physician, a physician’s assistant, an RN care manager, a psychiatry APRN, two Licensed Clinical Social Workers, a pharmacist, a Certified Diabetes Educator, four medical assistants, a Patient Services Representative, and a clinical manager.

The clinic "functions like a primary care office with more resources to coordinate care, treat mental health conditions, address financial challenges and manage complex medical issues," Johnson said during a presentation at the Maine Health Management Coalition earlier this year.

Whereas most primary care physicians can’t focus on acute care utilization, the Personalized Care Clinic can, all while coordinating and collaborating with a given patient’s unique team of specialists.

The PCC model does not replace primary care for vulnerable patient populations, Johnson and Henrickson said. Rather, it facilitates a “temporary transition of primary care, coordinating a patient’s treatment plan with primary care teams,” Johnson explained.

[See also: Intermountain, Deloitte put data to work.]

Intermountain’s Personalized Care Clinic lists its top five diagnoses as: other malaise/fatigue, depressive disorder, diabetes, anxiety (not otherwise specified) and backache NOS.

Though the Intermountain’s Personalized Care Clinic is still quite young, it does tend to a philosophy that is top of mind in healthcare.

“Our mission is helping people live the healthiest life possible,” Johnson concluded.