C-TAC Clinical Models Workgroup

Sheila Ryan

Sheila Ryan, RN, PhD, FAAN, University of Nebraska Medical Center and Clinical Models Workgroup Member

This Workgroup is developing a care-delivery model based on best practices to ensure high-quality, coordinated care — regardless of setting — for patients and their families living with serious illness.  This “Advanced Care” model is based on the clinical innovations of many of C-TAC’s members.

Based on an interdisciplinary care coordination model tightly linking inpatient, ambulatory and home/community settings, the workgroup has identified best-practices such as:

  • Care managers placed in the hospital, where they screen, risk-stratify, enroll and triage patients with advanced illness, and interface with hospitalists, inpatient palliative care and ED clinicians, inpatient case managers and discharge planners.
  • Other care managers embedded in physician group practices, where they provide consultation to physicians and office staff, enroll appropriate patients, and provide telephonic case management either from the office or from a centralized call center.
  • Mobile care management teams that provide high-touch encounters in patients’ residences, whether home or facility.
  • Constant real-time communication among all care managers and with the patient’s attending physician.

You can learn more about the Advanced Care Model the Workgroup is developing here.

Randy Krakauer, Co-Chair, Clinical Models Workgroup

Dr. Randall Krakauer graduated from Albany Medical College in 1972 and is Board Certified in Internal Medicine and Rheumatology. He received training in Internal Medicine at the University of Minnesota Hospitals and in Rheumatology at the National Institutes of Health and Massachusetts General Hospital/Harvard Medical School, and received an MBA from Rutgers. He is a fellow of the American College of Physicians and the American College of Rheumatology and Professor of Medicine at Seton Hall University Graduate School of Medicine. He is past chairman of the American College of Managed Care Medicine.

Brad Stuart, Co-Chair, Clinical Models Workgroup

Brad Stuart, M.D. was voted “Physician of the Year” in 2007 by the California Association for Health Services at Home. Dr. Stuart founded the Advanced Illness Management (AIM) program, which integrates hospitals, medical groups, and home- and community-based services to improve care and reduce costs for patients with late-stage chronic illness.

He is a founding Board member of the Coalition to Transform Advanced Care (C-TAC), a national organization dedicated to delivery system reform and policy change to benefit seniors with serious illness. Dr. Stuart attended Stanford University School of Medicine and provided primary care internal medicine for over a decade.

In 1996, he was the lead author of national Medicare hospice eligibility criteria for non-cancer disease, and has served on the National Quality Forum. He was featured in the HBO documentary Letting Go: A Hospice Journey, and wrote and hosted Care Beyond Cure: Hospice Helping Physicians Treat the Terminally Ill, a nationally televised special that won an International Angel Award for Media Excellence. He has written numerous book chapters and articles and lectured internationally on medical, psychosocial, and spiritual issues associated with serious illness.

To find out how you can get involved, please contact us.

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