The Comprehensive Care Program

Today, many patients have a primary care doctor who cares for them in the outpatient clinic. However, if they have to stay in the hospital, they usually get care from a doctor they do not know. This discontinuity in care can worsen patients’ health outcomes and experiences with care, particularly for those with multiple health problems. The Comprehensive Care Program includes two innovative care models that tackle this problem: the Comprehensive Care Physician (CCP) Program and the Comprehensive Care, Community, and Culture Program (C4P). Each offers patients with complex medical and social needs a comprehensive care physician who cares for them in both the hospital and the clinic. We firmly believe that strong relationships between patients and their doctors are key to better health and health care.

Since 2012, we have studied the CCP Program through a 2,000 person randomized trial with funding from the Center for Medicare and Medicaid Innovation (CMMI). CCP patients are Medicare beneficiaries and have been hospitalized at least once in the past year. Through the CCP Program model, patients and their families build meaningful relationships with their comprehensive care physicians. Our findings show that CCP patients experience significantly improved satisfaction with their care, improved mental health outcomes, and lower rates of hospitalization.

As we have gotten to know our patients better, we have quickly learned that improving medical care alone is not enough. We have found that a wide range of social barriers prevent almost a third of patients from engaging in the CCP Program. We developed the Comprehensive Care, Community, and Culture Program (C4P) to better engage patients in their care. The program seeks to both address social determinants of health and empower patients to better help themselves. In addition to receiving care from a CCP physician in both the hospital and the clinic, C4P patients are regularly assessed for unmet social needs, such as housing, food insecurity, public benefits, social engagement. C4P patients also receive access to a community health worker to help address their unmet needs.

Looking ahead, we have already started collaborating with other institutions both in and out of the United States, including through our Comprehensive Care Learning Collaborative. For more information about these or other opportunities, please request more information through the link below.

Interested in learning more about the CCP Program?

Hear what our patients have to say!

“Thank you so much for finding placement for me [in CCP]. Having the same doctor see me in the hospital as well as the clinic means so much to me. I can’t get that anywhere else and it makes me comfortable.


“[My CCP] has been very kind to me. She follows my health care even when I’m out of town. I genuinely love this woman and I want to do something nice for her. I’m so grateful to have her as my doctor; she provides excellent care.”


“[My CCP] goes above and beyond, every time. It’s your patience – it really means a lot to me.”