By Melinda Young


Case management leaders can learn from population health programs that successfully steer chronically ill patients to affordable clinics to help them manage their disease and stay out of the hospital and emergency department (ED).

• Research shows these programs can save money and increase patient engagement.

• One model used is STAND-UP, which stands for Smooth Care Transitions for Diverse and Underserved Populations.

• Population health programs might begin with grants, but leaders can make the case for hospitals funding these sustainably to reduce unnecessary hospitalizations and ED visits.

Hospital case management leaders have found their departments evolving in recent years, often to include practices and models that focus on population health goals. As care coordinators and case managers move toward transitions that incorporate these goals, one challenge is sustainability.

New research provides a model for sustaining a collaborative practice model that advances population health. Investigators determined engaged patients are highly satisfied with their care, including improved physical and mental health outcomes at a cost savings for the health system.1,2

“This research focuses on model sustainability,” says Maria Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAAN, professor and associate dean of the University of Alabama at Birmingham (UAB) School of Nursing. “We present a sustainability framework, showing the different elements in sustainability you need to keep it going.”

The Four Rights

The interprofessional collaborative practice (ICP) model includes Smooth Care Transitions for Diverse and Underserved Populations (STAND-UP). The ICP uses the Four Rights model: the right team with the right patient population with the right provider at the right time for care.2

Population health programs sometimes start with grants. If they are successful, it is important to find ways to make the programs sustainable for health systems.

“Look at the sustainability model: It identifies all the different things you have to consider to be able to continue. That is something you have to go into these efforts with,” she adds. “These include things like how to line up political support and partners to see the value of this work and how to sustain funding.”

For example, Shirey and colleagues built a business plan, using rich data and demonstrating a business case.

“When our grant was ending, we spoke with health system leadership at the hospital,” Shirey explains. “The outcomes we were producing were so superior that it didn’t make sense for them to stop the program. They needed to continue to fund us.”

The program focused on an underserved population that was using the emergency department (ED) extensively and in ways that were unnecessary if they received the ongoing care they needed, she says.

The UAB health system runs a heart failure and a diabetes clinic, which can keep patients healthier and help to avoid ED visits. “Both clinics follow a model of care that is an interprofessional theme, under one roof. We take care of the total patient,” Shirey notes. “We do primary care and specialty care focus, and we take care of comorbid conditions to the extent we can.”

The clinics will provide care to people who do not carry adequate health insurance or the income to pay for copays and medication.

“We can prescribe medications, but if patients don’t have money, they don’t take medicine and they won’t improve,” Shirey says. “We have a patient assistance program that provides medication, and we have a Dispensary of Hope affiliation with a pharmacy.” The Dispensary of Hope distributes medications to pharmacies and safety-net clinics for low-income, chronically ill patients. (For more information, visit:

UAB uses a bundle in which patients receive care coordination from a social worker and a clinical nurse leader. Patients are monitored continuously. Staff know if patients are home, hospitalized, or receiving treatment in the clinic or ED. “Our goal is to keep them home with their families, functional to the best possible in their disease state, and to keep them out of the ED,” Shirey explains

This is accomplished through evidence-based guidelines, patient activation, and care coordination, Shirey notes.

Integrate Behavioral Health

Behavioral health integration also is part of the program. “A lot of these patients have mental health issues and substance abuse,” Shirey says. “It’s very difficult to take care of them if you don’t take into consideration those other aspects.”

For example, some patients are depressed and do not take care of themselves because of untreated depression. “They don’t take their meds or eat right, and they get into a vicious cycle,” Shirey says. “If we see a patient is depressed in our protocol, we have services to offer them in our clinic: psychiatric mental health, psychologist, and others.”

Patients are prescribed antidepressants and connected with support groups, as needed. “If you can improve the depression, then you can improve their ability to better care for themselves,” Shirey adds.

The program’s care coordination function is led by a clinical nurse leader. “She keeps track of where each patient is in the continuum of care, and she knows what that patient’s plan of care is,” Shirey says.

The care model includes medication reconciliation with patients at each visit. “Our patients keep journals. so The clinical nurse leader reviews their journals and makes assessments of where the patient is relative to their plan of care and feeds this information to the nurse practitioner, who will see the patient for that visit,” Shirey says. “The other aspect of the clinical nurse leader role is they’re not only involved in the actual care component, but also are good at analytics, keeping data, and monitoring outcomes.”

The bulk of the program’s funding comes from the hospital because of what it saves the health system, Shirey notes. “The quality of our care is exceptional. Our outcomes show we improve physical and mental health and improve access to care.”

Patients’ lengths of stay are shortened, and they are admitted to the hospital only when medically necessary.

“In our clinic, we can see patients in less than seven days, and there are times when we can see a patient on the day we receive a provider referral,” Shirey says.


  1. Shirey MR, Selleck CS, White-Williams C, et al. Interprofessional collaborative practice model to advance population health. Popul Health Manag 2020; Feb 19. doi: 10.1089/pop.2019.0194. [Online ahead of print].
  2. Shirey MR, Selleck CS, White-Williams C, et al. Sustainability of an interprofessional collaborative practice model for population health. Nurse Adm Q 2020;44:221-234.