How the Stanford Coordinated Care model improved outcomes, reduced costs, and restored joy in medicine.
Early in his career, Dr. Alan Glaseroff and his wife Dr. Ann Lindsay – his longtime medical and professional partner – saw firsthand the evolution of primary care from an independent, community-based model to one increasingly burdened by administrative complexity.
“When we started in the early 1980s, our overhead was about 25% of revenue,” he said. “By the time we left for Stanford, it was up to 65%,” driven by growing documentation requirements and insurance denials that added layers of work to patient care.
During his time practicing primary care in Humboldt County, Dr. Glaseroff led a landmark community-wide effort to improve diabetes outcomes. With support from the California Health Care Foundation, his team built a shared registry of 8,300 patients – representing 95% of all residents with diabetes in the county. Over eight years, the initiative reduced deaths from diabetes by 29% in Humboldt, while across California there was no reduction in deaths over the same period.
That success caught the attention of Dr. Arnold “Arnie” Milstein of Stanford University’s Clinical Excellence Research Center, and a national leader in high-value care. Dr. Milstein recruited Dr. Glaseroff and his wife to help build on those lessons through a new model of coordinated, team-based primary care. Dr. Glaseroff’s work began in Humboldt as “Priority Care,” evolving into what would become Stanford Coordinated Care, a program designed to support patients with complex chronic conditions while reducing costs and improving quality – a continuation of Dr. Glaseroff’s lifelong mission to make healthcare both compassionate and sustainable.
When Drs Lindsay and Glaseroff arrived at Stanford University in 2011, they were tasked with designing an entirely new kind of primary care program – one that would challenge traditional incentives and focus on patients with the greatest health needs. The primary goals were to improve outcomes and reduce costs for Stanford’s own employees, a diverse population that ranged from groundskeepers and custodians to professors and Nobel laureates.
“The key challenge,” Dr. Glaseroff said, “was the payment model. Misaligned incentives make it hard to do the kind of work that really helps patients.” Traditional fee-for-service systems reward volume, not coordination, and tend to overlook the complex needs of patients with multiple chronic conditions.
The Stanford model centered on transforming medical assistants into care coordinators – also known as community health workers – who help patients navigate appointments, medications, and daily health challenges. “They go by different names,” he said, “but it’s the same essential job: helping people manage their lives so they don’t keep ending up in the hospital.”
Launching the program required navigating Stanford’s intricate ecosystem of hospitals, health plans, and academic departments. The clinic’s initial focus was on the top 5% of patients predicted to account for 50% of healthcare spending. These patients often had multiple illnesses and high utilization rates, making them ideal candidates for intensive, coordinated care.
By spring 2012, the Stanford Coordinated Care clinic opened its doors. Supported by senior hospital leadership, the program became a test case for how academic medical centers could deliver compassionate, cost-effective care. “The U.S. spends twice as much on healthcare as any other country,” Dr. Glaseroff said. “Our mission was to prove that focusing on the people who need the most help could actually make the whole system work better.”
First steps
The Stanford Coordinated Care program is rooted in one deceptively simple step: listening. Before the clinic even opened, they interviewed potential patients from across Northern California – people who had received care through Stanford, Kaiser, Sutter Health, or private practices – and asked what wasn’t working in their healthcare experiences. The responses shaped everything that followed.
What they heard was frustration. Patients felt unseen, unheard, and overwhelmed by a fragmented system that treated their illnesses but rarely addressed their lives. “We started by asking, ‘What’s bad about the care you’re getting?’” Dr. Glaseroff recalled. “And we built from there.”
At the time, Stanford University had only about 15 primary care physicians for its 33,000 employees. The Glaseroffs needed to create a new model – one that could deliver deep, personal care, especially for patients with multiple chronic conditions.
Instead of hiring typical medical assistants, they sought out individuals who had shown a desire to go above and beyond for patients.
These medical assistants – renamed care coordinators – were drawn to healthcare by a desire to help others. But in traditional settings, their compassion was often considered time-consuming and inefficient. At SCC, that empathy became their greatest asset. Care coordinators received special training in behavioral health, motivational interviewing, and patient coaching. They sat in on visits, scribed notes into electronic records, and built genuine relationships with patients.
“Half their day was spent seeing patients; the other half was spent checking in on everyone else – calling, texting, finding out how people were doing,” Dr. Glaseroff explained. “Because what happens between visits matters more than what happens during them.”
Designing care around patients’ lives
The SCC model was structured on the belief that patients can take control of their own health. Instead of simply prescribing changes, care coordinators helped patients define goals and take small, achievable steps. A patient who wanted to start exercising, for example, would leave the visit with a concrete plan – what day, what time, and with whom – and a follow-up call to check progress.
This approach helped transform healthcare from a series of disconnected appointments into a continuous, supportive relationship. Patients were encouraged to explore how their past experiences affected their health. Every new patient was asked a single, open-ended question: “How was your childhood?”
That one question opened doors. Many revealed experiences of trauma, neglect, or abuse – factors now known to significantly influence adult health through the Adverse Childhood Experiences (ACE) framework. About 40% of patients ultimately received behavioral health therapy at the clinic, often for trauma-related issues, depression, or anxiety.
Physicians, therapists, pharmacists, and care coordinators all worked together in one open space. “We called it Extreme Team Care,” said Dr. Glaseroff. “Everyone was in the same room – 12 workstations around the walls, tables in the center. If I had a question about a patient, I could just turn around and ask.”
The clinic included a behavioral health specialist, a clinical pharmacist (especially valuable since 58% of patients had diabetes), and physical and occupational therapists. This integrated approach eliminated silos and allowed for rapid collaboration.
The clinic also applied Lean methodology, inspired by the Toyota Production System, to continuously improve processes. Each staff member was empowered to identify inefficiencies and propose solutions. “It was the most joyous place I’ve ever worked,” Dr. Glaseroff said. “Everyone loved it. And we had near-zero turnover – unheard of for medical assistants.”
Data transparency and accountability
To track progress, the team developed a risk registry for patients – an interactive dashboard with roughly 50 indicators such as blood pressure, glucose control, and medication adherence. Patients could see their results coded in red, yellow, and green. The visual simplicity inspired accountability.
“When we showed patients their charts, they’d say, ‘What’s all this red? I don’t like it,’” Dr. Glaseroff said. “We’d tell them, ‘That’s where you’re in danger.’ And they’d say, ‘I want to get the red out.’ We called it the Visine Moment.”
By making data visible and empowering patients to act, the clinic fostered a sense of ownership rarely seen in primary care.
Half of each day was intentionally left unscheduled, allowing same-day or urgent appointments. If a patient called in distress, they could see their care coordinator or provider immediately – often the same person they knew and trusted. This eliminated much of the frustration that drives patients to emergency rooms.
As a result, the clinic achieved extraordinary outcomes:
- ER visits dropped to near zero.
- Hospital admissions declined by more than 50%.
- Patient satisfaction reached the 99th percentile nationally, as measured by Press Ganey surveys.
For five consecutive years, Stanford Coordinated Care maintained top-tier rankings in both quality and experience. Patients described feeling cared for as human beings, not just as cases or diagnoses.
A new vision for primary care
The clinic’s model reflected principles of human-centered design. Every feature from appointment structure to team layout was shaped by real patient feedback. “We gave people what they told us they wanted,” Dr. Glaseroff said. “That’s the secret.”
The program’s success drew national attention. The Lindsay-Glaseroffs were invited to present at the Institute for Healthcare Improvement (IHI), where they led “learning laboratories” for hundreds of participants eager to replicate the model. Working with the Pacific Business Group on Health, they secured a $19 million federal grant from the Centers for Medicare and Medicaid Innovation to expand the approach to 23 medical organizations across five states.
At its core, Stanford Coordinated Care proved that redesigning primary care around empathy, teamwork, and patient empowerment could dramatically improve outcomes, and joy in practice, without increasing costs.
“The U.S. healthcare system is built around transactions,” Dr. Glaseroff reflected. “We built ours around relationships. Once patients know they’ve been heard, they trust you. And when they trust you, they get better.”
For Dr. Glaseroff and his team, success wasn’t just about lowering hospital admissions or achieving top patient scores – it was about restoring meaning to medicine. “We created a place,” he said, “where everyone – the staff and the patients – wanted to be.”
Spreading the model
Dr. Glaseroff doesn’t just believe the Stanford Coordinated Care model can be replicated – he’s seen it happen. One of the clearest examples, he said, was at Bellin Health in Green Bay, Wisconsin, where physician burnout had reached a breaking point. Doctors were threatening early retirement, disillusioned by long hours, paperwork, and the emotional toll of fragmented care. “They said, ‘Can you fix that?’” Dr. Glaseroff recalled. Bellin leaders came to Stanford for intensive training, learned the coordinated care model, and brought it back home. “Once it got implemented, the doctors rescinded their retirement letters,” he said. “It was the most joyous place to work I have ever been.”
The model wasn’t just about happier doctors – it created better teams and stronger patient relationships. Dr. Glaseroff described how every member of the care team, from physicians to medical assistants, had a shared purpose rooted in listening, empathy, and patient activation. He recalled how one patient, after recovering from a life-threatening condition, told him, “You saved my life. I love you. Can I give you a hug?” But what moved Dr. Glaseroff most was what came next: the patient asked, “Will Delilah still be here?” referring to his care coordinator. “That mattered as much to him as me,” he said. “That’s team care.”
Over several years, Stanford’s Coordinated Care Center became a training ground for others – 15 organizations came to learn its methods. The results were consistent: less burnout, higher satisfaction, and more meaningful patient outcomes. Still, scaling the model nationwide remains difficult. The barrier, Dr. Glaseroff explained, isn’t clinical – it’s financial. “We live in a fee-for-service environment where there’s almost no incentive for primary care,” he said. In that system, long visits, monthly touchpoints, and home calls are considered inefficiencies, even when they keep patients healthier.
Dr. Glaseroff contrasted that reality with Medicare Advantage, where he said the profit motive often undermines patient-centered innovation. “The way to control costs is to have people do better,” he said. “And it’s by focusing on the top 5% who drive half the spending each year.”
For Dr. Glaseroff, who has lived with type 1 diabetes since early in his career, the lesson is deeply personal. “I understood what it was like to be a patient,” he said. That experience shaped his conviction that activating and empowering patients – through listening, empathy, and peer support – is the key to better care. “Stop scaring people,” he often tells clinicians. “Start helping them believe they can succeed.”
Patient participation in their own health care
Dr. Alan Glaseroff emphasizes that patient participation is central to effective primary care. He points to the work of Kate Lorig, a nurse and Ph.D. who developed the Chronic Disease Self-Management Program at Stanford. This program empowers patients to manage their own health through peer-led group visits, rather than relying solely on healthcare professionals. Dr. Lorig’s approach demonstrates that patients can take an active role in their care when given the right tools and support.
Complementing this, Judith Hibbard, an emeritus professor at Oregon Health Sciences School of Medicine, developed the Patient Activation Measure (PAM), a validated tool that assesses a patient’s ability and confidence to manage their own health. PAM scores provide a clear way to predict which patients are likely to succeed in managing their conditions and which may need more intensive support. By combining Lorig’s strategies with PAM measurement, primary care teams can systematically improve patient activation, enabling individuals to take control of their health outcomes.
The foundation of these approaches lies in the psychological concept of self-efficacy, introduced at Stanford by psychologist Albert Bandura. Self-efficacy asks: can a person organize their life to manage their health effectively? By measuring and improving self-efficacy and measured through PAM, patients can progress from feeling helpless to confidently managing their conditions — even amid significant life challenges.
Dr. Glaseroff stresses that this focus on behavioral change is the core of primary care and the main driver of healthcare costs. Yet, he notes a major barrier: the U.S. fee-for-service payment system, with short, underpaid visits, makes it nearly impossible to provide the time and support patients need to truly activate themselves. For Dr. Glaseroff, empowering patients is a measurable, replicable strategy that improves outcomes and reduces costs when implemented effectively.
About the program
Drs. Alan Glaseroff and Ann Lindsay launched Stanford Coordinated Care (SCC) in 2012 to provide comprehensive care to high-risk, high-cost employees and dependents of Stanford University. As a service of the self-insured health plan, SCC aims to reduce hospital and emergency room use, improve care quality, and enhance patient health and satisfaction. All Stanford employees and their dependents, from support staff to faculty, are eligible to participate.