Journal of General Internal Medicine

, Volume 33, Issue 11, pp 1937–1944 | Cite as

Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies

  • Donna M. ZulmanEmail author
  • Colin W. O’Brien
  • Cindie Slightam
  • Jessica Y. Breland
  • David Krauth
  • Andrea L. Nevedal
Original Research



Intensive outpatient programs address the complex medical, social, and behavioral needs of individuals who account for disproportionate healthcare costs. Despite their promise, the impact of these programs is often diminished due to patient engagement challenges (i.e., low rates of patient participation and partnership in care).


The objective of this study was to identify intensive outpatient program features and strategies that increase high-need patient engagement in these programs.


Qualitative study.


Twenty program leaders and clinicians from 12 intensive outpatient programs in academic, county, Veterans Affairs, community, and private healthcare settings.


A questionnaire and semi-structured interviews were used to identify common barriers to patient engagement in intensive outpatient programs and strategies employed by programs to address these challenges. We used content analysis methods to code patient engagement barriers and strategies and to identify program features that facilitate patient engagement.

Key Results

The most common barriers to patient engagement in intensive outpatient programs included physical symptoms/limitations, mental illness, care fragmentation across providers and services, isolation/lack of social support, financial insecurity, and poor social and neighborhood conditions. Patient engagement strategies included concrete services to support communication and use of recommended services, activities to foster patient trust and relationships with program staff, and counseling to build insight and problem-solving capabilities. Program features that were identified as enhancing engagement efforts included: 1) multidisciplinary teams with diverse skills, knowledge, and personalities to facilitate relationship building; 2) adequate staffing and resources to handle the demands of high-need patients; and 3) a philosophy that permitted flexibility and patient-centeredness.


Promising clinical, interpersonal, and population-based approaches to engaging high-need patients frequently deviate from standard practice and require creative and proactive staff with adequate time, resources, and flexibility to address patients’ needs on patients’ terms.


patient engagement patient-centered care primary care vulnerable populations care management 



The authors would like to thank the following program representatives for their study participation and contributions to this project: Robert Carr, Anna Chodos, Elizabeth Davis, Nate L. Ewigman, Brenda Goldstein, Courtney Gray, Kathryn Holloway, Debra Hummel, Debra Keller, Michael Kern, Ann Lindsay, David Moskowitz, Kathy O’Brien, Delila Pellot, Maria C. Raven, Laura Rombach Rau, Rebeca Servin, Jonathan Shaw, Ramona Soberanis, and Kathryn Stambaugh. We would also like to thank Steven Asch and Mary Goldstein for providing guidance during conceptualization of this project, and we would like to acknowledge content experts Clemens Hong, Ming Tai-Seale, and Brook Watts for reviewing and contributing to the list of patient engagement barriers that formed the basis of interviews.


The study was supported by Veterans Affairs HSR&D Career Development Awards (CDA 12-173 and CDA 15-257) and a Stanford University School of Medicine MedScholars grant. Funding agencies had no role in the study’s design, conduct, or reporting.

Compliance with ethical standards

This study was approved by the Stanford University Institutional Review Board.

Prior presentations

This work was presented at the annual meeting of the Society of General Internal Medicine, May 12, 2016 in Hollywood, FL, and at AcademyHealth on June 25, 2018 in Seattle, WA.

Conflicts of interest

The authors declare that they have no conflict of interest.

Supplementary material

11606_2018_4608_MOESM1_ESM.docx (26 kb)
ESM 1 (DOCX 25 kb)


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Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2018

Authors and Affiliations

  • Donna M. Zulman
    • 1
    • 2
    Email author
  • Colin W. O’Brien
    • 3
  • Cindie Slightam
    • 2
  • Jessica Y. Breland
    • 2
  • David Krauth
    • 2
  • Andrea L. Nevedal
    • 2
  1. 1.Division of Primary Care and Population Health Stanford University School of MedicineStanfordUSA
  2. 2.Center for Innovation to Implementation, VA Palo Alto Health Care SystemMenlo ParkUSA
  3. 3.School of MedicineStanford UniversityStanfordUSA

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