Care Redesign
Relentless Reinvention

Effective Treatment of Congestive Heart Failure Through a Health System–Community Clinic Partnership

Case Study · February 5, 2017

San José Clinic (SJC), founded in 1922 as the original safety-net clinic in Houston, Texas, is a leading provider of quality health care services for patients who struggle the most with accessing care. Our unique model relies on more than 800 volunteers, including 700 medical professionals across all specialties. Volunteers contribute more than 23,000 hours of service each year. Through academic affiliation agreements with the nearby Texas Medical Center institutions, the clinic allows faculty, residents, and students to do community health rotations. The clinic also has strong relationships with clinicians in private practice, who take time out of their own office schedules to volunteer. Many work with us during retirement as well.
The clinic has only 50 full-time employees but still provides high-quality, low-cost care because of its volunteers. The total budget for 2015 was about $10 million. Funding comes from the Archdiocese of Galveston-Houston, the United Way, individual and corporate donors, in-kind donations for specific services, and patient contributions to care (which make up about 8% of annual revenues). The CHRISTUS Health Foundation underwrites the cost of our 33,000 square feet of clinical space within the building.

The Challenge

The personal health and financial burden of congestive heart failure (CHF) is substantial. There are currently approximately 6 million CHF patients in the United States, and the number of adult patients with CHF is expected to increase to 8 million by 2030. The expected cost of caring for heart failure is expected to increase as well, from $31 billion in 2012 (or $6,200 per patient per year) to $70 billion (or $8,750 per patient per year) by 2030. Uninsured CHF patients are at particularly high risk for complications and hospitalizations, with high associated costs, because they lack routine access to outpatient care.

In 2014, San José Clinic was approached by CHI St. Luke’s Health–Baylor St. Luke’s Medical Center (CHI), which had established a transitional care clinic (TCC) for its post-discharge CHF patients to make sure they had consistent follow-up care, education, and counseling. While patients with insurance eventually returned to being monitored by their normal primary care providers, CHI was having difficulty finding appropriate ongoing care for uninsured CHF patients, who number a few dozen in any given year and are at high risk for readmission if not carefully monitored. The two organizations already had a working relationship, and SJC had capacity to accommodate the patient population. SJC sought to create a medical home for comprehensive care management for these patients.

The Goal

Coordination between inpatient and outpatient care teams plays a key role in keeping CHF patients stable and out of the hospital after an inpatient stay, but there is currently no mechanism for creating this type of coordination for uninsured patients, who do not have a payer with a vested financial interest in keeping them out of the hospital. The overall goal of the partnership between CHI and SJC was to create a care transition program to coordinate care for these patients and give them a stable source of ongoing monitoring and follow-up treatment.

Specific goals of the partnership included:

  • Develop co-management strategy for heart failure in the uninsured population
  • Subsidize care during the transition period from post-acute care to a community setting
  • Provide a stable primary care–based medical home for patients
  • Provide comprehensive preventive care, including primary care, individualized education, and screening services
  • Reduce readmissions to CHI as partner hospital

Benefits of the program included:

  • For patients, improved health and access to additional services
  • For CHI, cost savings due to reduction in uninsured CHF admissions and readmissions
  • For SJC, compensation for delivery of services during the patient’s transition period

The Execution

SJC partnered with the CHI Transitional Care Clinic. CHI paid for each patient’s first four visits to SJC to offset the upfront costs of establishing the patient relationship (e.g., initial lab work, specialist consultations). Patients were referred to SJC after an initial meeting with a TCC team member to explain the partnership with SJC and its role as the patient’s medical home.

SJC-CHI Congestive Heart Failure Care Process

  Click To Enlarge.

The project was designed to expedite the establishment of the patient’s relationship with SJC in order to detect and avert complications that might lead to a readmission. SJC Patient Care Coordinators work with the CHI Transitional Care Clinic to ensure that patients receive a first appointment within 7 days of the initial referral. The SJC eligibility process is started upon referral, and after the fourth visit patients are seamlessly transitioned over to SJC as their medical home. At that point, SJC takes over financial responsibility for their care. Over the course of those first four visits, the patient is navigated into primary care, medication therapy monitoring, and cardiology. SJC is also able to provide social support services to patients, including transportation, familial support, lifestyle coaching, and nutrition counseling.

Scope of Services

Chronic Disease Management from Multidisciplinary Team

  • Physician (family medicine, internal medicine, cardiology)
  • Clinical pharmacist (medication therapy management)
  • Nutritionist
  • Physical therapy
  • Behavioral therapy

Educational Resources

  • Nutrition
  • Smoking cessation
  • Exercise
  • Weight management
  • Substance abuse
  • Caffeine consumption
  • Adult immunization (influenza, pneumonia, and shingles)

Medication Therapy Management

  • Medication reconciliation
  • Medication adherence
  • Medication optimization
  • Medication titration
  • Avoid drug/drug or drug/disease interactions
  • Identify and address duplications in therapy
  • Ensure medications have a proper indication and each indication is properly medicated
  • Optimize dosages to maximize therapeutic outcomes
  • Monitor adherence and address issues related to non-adherence

Additional Challenges

At the beginning of the partnership, CHI and SJC addressed key issues including partnership dialogue, program design, coordination of care team model, health outcomes, and total cost savings to the hospital partner.

As the collaboration progressed, additional challenges arose, including:

  • Establishing which diagnostic tests, labs, and referrals would occur during the patient’s first four visits. (This list changed and expanded as the care team identified which services would have the most impact.)
  • Prioritizing the eligibility process to qualify patients for ongoing SJC services. Initially, the SJC eligibility process was not started until the end of the fourth visit, which delayed subsequent visits and access to other clinic services.
  • Adding echocardiogram capability at SJC. Currently, SJC has no staff or volunteers to perform echocardiograms for our patients, so, for a time, patients needing this service were being referred back to CHI. However, as of late 2015, CHI can no longer financially support this service, so patients are now referred to other community partners at the patient’s expense.
  • Ensuring timely referral. The initial goal was to have patients seen within 7 days of referral. Occasionally, this does not occur due to socioeconomic factors. SJC was able to establish a process with CHI to reach out to patients who do not keep their appointments.


Since the program’s inception, SJC has provided care for 57 uninsured CHF patients referred from CHI and has achieved a 90-day readmission rate of 10.5%, which is lower than the readmission rate of 14% for insured CHF patients seen at the Transitional Care Clinic at CHI. Based on that difference in readmission rates, the program has prevented between two and three readmissions, each of which would have cost CHI an average of almost $13,000. CHI paid SJC a total of $37,962 for the care provided to these patients during their first four visits to SJC, detailed in the chart below. The average cost per visit was $73.

Services Provided at SJC to Uninsured Congestive Heart Failure Patients Referred from CHI

  Click To Enlarge.


We understand that SJC is a unique environment with generous funding and strong academic partners; however, this should not preclude community health centers around the country from trying to implement similar arrangements with nearby health systems. We believe our model is replicable and would offer mutual financial benefit to both parties, regardless of the underlying clinic funding mechanism. CHI reduces its cost burden by co-managing and transitioning patients to SJC, which provides appropriate care to help patients stay healthier. Although CHI subsidizes the establishment of the medical home relationship, its total costs to care for these patients are reduced somewhat even in the short term, and we expect that they will be reduced even more in the long term.


Acknowledgments: The authors would like to acknowledge Victoria Muir-Locklin, RN; Lana Langlinais-Romero, RN, BSN, Med.; Norma Covarrubias, RN, BSN; Richelle Dixon, MHSA, Vice President, Ambulatory Care; Bernita G. Chance, RN, MSN, FNP.

This case study originally appeared in NEJM Catalyst on December 21, 2016.

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