Table 1.

Details of intensive outpatient programs in the literature review and qualitative interviews

Program or Author Name	Population Characteristics	Recruitment Method	Care Team	Program Length	Setting	Sample and/or Panel Size	Geographic Region
Special Care Center [3]	Low wage Immigrant Non-White (83%) Non-English speaking (58%) Multiple chronic conditions	NS	2 full time physicians 2 nurse practitioners 7 health coaches 1 admin. director/licensed social worker 2 client services reps 1 part time nutritionist 1 consulting psychiatrist	NS	Integrated health care system	Sample: 1000+ patients per year Panel: Each health coach managed 80-150 patients	Atlantic City, New Jersey
Raven et al. [17]	Active substance abusers (95%) Homeless (89%) White (47%) Hispanic (32%) Multiple chronic conditions	Algorithm used to identify eligible patients admitted 24 hours prior, all eligible patients approached for enrollment while in hospital	Case manager Project director MSW Physician	NS	Public hospital	Sample: 19 Panel: NS	New York City, NY
King County Care Partners [18]	Non-White (45%) Multiple chronic conditions	Clinical team given a list, one team member contacted patients	3 RNs 2 MSWs with chemical dependency training A bachelor’s level individual trained in chemical dependency counseling	Up to 1 year	Integrated into safety net primary care system; RCT	Sample: 256 Panel: 67-70 clients per RN/team	King County, Washington
Intermountain Healthcare [19]	NS	Patients referred based on need	Physician Medical assistant Care manager Office manager	NS	Integrated health care system	Sample: 2,356 Panel: NS	Utah and Idaho
Okin et al. [20]	Male (87%) African-American (49%) Unemployed (67%) Homeless (67%)	Patients referred by ED staff and screened by case managers	Case Manager Psychiatric social worker	1 year	Hospital with high collaboration between case managers and ED, and inpatient and PCP. Social work role was to improve linkage to PCP.	Sample: 174 Panel: NS	San Francisco, CA
Medicare Coordination Care Demonstration [21] (represents 11 programs)	Medicare beneficiaries: lived within program’s catchment area Covered by fee for service Medicare with primary Part A and B coverage Had one or more of the program’s target chronic conditions (varied by program)	Patients voluntarily enrolled in programs at any point during the five years after its 2002 start date	Common feature includes RNs as care coordinators	NS	Community hospitals, academic medical center, integrated delivery system, hospice, and long-term care facility	Sample: 22,000 Panel: NS	Across the United States
Primary Intensive Care [22]	White (82%) Covered by Medicaid or Medicare Multiple chronic conditions	Patients referred by PCP or inpatient care coordinator	Internist Psychiatrist-internist Nurse practitioner Pharmacist Social worker	5-12 months	Hospital	Sample: 20 Panel: NS	NS
Rethinking Care [23]	White (57%) Serious mental illness (49%)	Patients identified as being in the top 20% of clients at risk for high healthcare costs were contacted by research team	Nurse care managers Social worker Physician Clinical care coordinator	up to 2-years	Community health centers; RCT	Sample: 690 Panel: NS	Washington
Shumway et al. [24]	Non-White (87%) multiple chronic conditions	Patients identified through medical records, eligibility determined through interviews, case manager supervisor conducted final evaluation	MSW Nurse practitioner PCP Psychiatrist	2-year	Hospital; RCT	Sample: 167 Panel: NS	San Francisco, CA
Intensive Management Patient-Aligned Care Team (ImPACT) [2]	White (79%) Multiple chronic conditions	Algorithm identified high-need, high-risk patients; Study team contacted eligible patients via phone, mail, and/or at appointments	RN MSW RT Physician	NS	Integrated health care system; RCT	Sample: 150 Panel: 150	Palo Alto, CA

Admin: Administrative; ED: Emergency department; MSW: Social Worker; NS: Not specified; PCP: Primary care physician; RCT: Randomized controlled trial; Reps: Representatives; RN: Registered Nurse; RT: Recreation Therapist

Note: Dorr and colleagues [19] provide additional information on Intermountain Healthcare [31]. Lessler and colleagues [18] provide additional information on King County Care Partners.[23] Okin and colleagues[20] provide additional information on the program described by Shumway and colleagues [24].