U Magazine
U Magazine
UCLA Health
David Geffen School of Medicine

Connecting the Dots

In the increasingly complex world of modern medicine, care coordinators are there to link patients to necessary services and make sure they never feel that they are left on their own.

  Marjorie Crear
  Tiffany J. Phan
  “She calls to see if I’m taking my medications and if the home-health nurse has come out,” says Marjorie Crear (top) of her care coordinator, Tiffany J. Phan (bottom). “I was so surprised [to learn] that somebody else was going to help me.”

By Shari Roan

Photography by Ann Johansson

Marjorie Crear is like many people who aretermed heavy users of healthcare. The 66-year-old Los Angeles woman has diabetes and hypertension. She recently suffered a stroke and needed rehabilitative care. She’s had a heart attack, too. Crear lives alone on a fixed income and doesn’t drive. She’s had to dial 911 for an ambulance more times than she can count.

But with the new medical-home program launched at UCLA to assist individuals with serious chronic-health issues and limited resources, Crear’s circumstances are improving. She was assigned to a comprehensive-care coordinator, a trained individual who works alongside Crear’s primary-care doctor. Crear’s care coordinator makes sure she schedules her doctors’ appointments, monitors her blood sugar and knows who and when to call if she’s not feeling well. Her care coordinator is even helping her find housing that’s more suitable for someone with physical limitations.

“She calls to see if I’m taking my medications and if the home-health nurse has come out,” Crear explains, adding that she was stunned when her primary-care doctor told her about the care-coordinators program. “I was so surprised that somebody else was going to help me.”

The care-coordinators program at UCLA is part of a transformation designed to address several of the thorniest issues in contemporary healthcare, such as the over-utilization of emergency-room services and fragmentation between primary-care doctors and specialists that allows patients to fall through the cracks.

A U.S. population that is aging and rife with chronic conditions means that everyone has to think about new ways to ease the strain on the healthcare system while improving outcomes. The goal is to try harder to keep healthy individuals well — such as by making sure people obtain recommended screening tests and immunizations — as well as stabilizing the health of chronically ill people who tend to lurch from one medical crisis to the next.

Care coordinators may be among the solutions.

“The imperative right now in healthcare is that we have to do better,” says Tom Rosenthal, MD, chief medical officer for UCLA hospitals. “We have to deal with people with chronic disease better, and we have to use resources more efficiently. We don’t know how to do that precisely. There isn’t a road map on how to do that. Consequently, we have to be innovative.”

Healthcare is shifting from focusing only on individual patients to a perspective that also considers the well-being of entire populations, Dr. Rosenthal explains. It looks beyond the most pressing situations — patients who need acute care in hospitals — to engage communities. Technological developments, such as electronic medical records, have turned the concept of population-health management into a real possibility.

In primary-care doctors’ offices, that means reaching out to people who aren’t coming in for regular healthcare, says Michael Ong, MD, PhD, associate professor of medicine and an expert on healthcare economics. “In primary care, it’s very easy to focus on the patients just in front of you,” he says. “But there are also the patients who don’t come in whom we should be thinking about. When they’re not in front of us, we’re going to forget about them.”

Forgotten patients may include those who are too frail to go to the doctor on a regular basis, who lack transportation or financial resources or who distrust the healthcare system. “They are patients with one or more chronic diseases who are on multiple medications, in and out of skilled-nursing facilities, in transition to hospice care, have socioeconomic barriers that make it difficult to navigate the healthcare system on their own or patients who have complicated care plans,” says Jordan M. Hall, director of population-health management and comprehensive-care coordination for UCLA.

  Dr. Samuel A. Skootsky
  “One of the goals of the program is to improve the patients’ experience of care,” says Dr. Samuel A. Skootsky, chief medical officer of the UCLA Faculty Practice Group and Medical Group.

KEEPING THOSE PEOPLE LINKED TO REGULAR HEALTHCARE is the goal of the care-coordinators program. While care coordinators working in UCLA’s hospitals are RNs, those in outpatient settings may be RNs or come from other backgrounds such as social work or veterans who have served as medics. They are trained to work in a doctor’s office to troubleshoot patient-care issues under the supervision of the medical team, Hall explains. Care coordinators make sure the doctors’ care plans are being implemented and contact patients who have missed an appointment to find out why. They arrange patient transportation to the office if needed or work with the patient’s insurer to facilitate coverage of care. They track down records needed for an upcoming visit. They answer patients’ phone calls and either resolve their issues or arrange for the doctor to speak with the patient. Patients receive prompt, efficient help, and doctors and nurses are freed up to focus on medical issues.

“Our goal is to provide patients with better healthcare and a better patient experience when they come to UCLA,” Hall says. “We want to reach out to these populations to make sure they get timely exams, follow-up care and preventive care for healthy people. We want to do it in the appropriate setting.”

A major concern in healthcare in recent years is the high number of people who seek treatment in hospital emergency rooms because they don’t know where else to go or don’t have a relationship with a primary-care doctor. “That is where patients get lost in the system,” Hall says. “They don’t feel well and go to the emergency room. But there is an office that can really improve outcomes in a more timely matter. Our care coordinators and clinical advisors provide patients with resources and are able to help them connect the dots.”

The model aims to create a one-stop experience for patients, too. For example, in the UCLA medical-home model, pharmacists are on site one day each week to help patients with medication issues. Called MyMeds, the program includes helping patients learn if less-costly medications are available and ways to simplify medication schedules to improve adherence.

“We try to bring components to the practice that traditionally haven’t been there before,” Hall says. “What we’re doing is providing all services in one place, the patient’s primary-care office. And we’re trying to understand the patient from head to toe. Sometimes the barrier to care might not be the patient but a family member or someone who doesn’t fully understand the situation.”

In the past, primary-care doctors have referred patients for behavioral-health treatment but couldn’t be assured that the patient received services, says Samuel A. Skootsky, MD (RES ’82, FEL ’83), chief medical officer of the UCLA Faculty Practice Group and Medical Group.

“That is a general problem in primary care. Doctors would refer patients, but they wouldn’t even know if the patients got seen,” he says. To address this problem, UCLA has hired behavioral-health specialists to work with the primary-care offices. “Hiring our own internal behavioral-health team is a significant innovation,” he says. Future plans include a program to link primary-care doctors with other types of specialists to ensure that patient care is coordinated.

  Dr. Marcia Colone
  “Healthcare is complicated,” says Dr. Marcia Colone, UCLA Health director for care coordinators and clinical social work. “We need a system that is responsive to helping patients and families sort out their next steps ... to make the best decisions.”

THE HOSPITAL CARE-COORDINATORS PROGRAM ALSO BRIDGES THE GAPS that sometimes occur between inpatient and outpatient care. Hospitalized patients who may have trouble transitioning to home care, rehabilitation facilities, hospices or nursing homes can be referred to a care coordinator for assistance. By smoothing the move from the hospital, experts hope to bring down the high rate of patient readmissions — returning to hospital care within 30 days of the previous discharge — a vexing problem for hospitals nationwide. “Anyone can refer a patient to our services,” says Marcia Colone, PhD, system director for care coordination and clinical social work at UCLA. “Anyone can say he thinks a patient will need help at discharge or need help with a payer. We arrange an array of post-discharge services.”

The hospital program offers temporary assistance to homeless patients who have nowhere to go when they leave the hospital and endeavors to keep them connected to healthcare. But even patients with insurance, homes and families can find a hospital stay disorienting or can be confused by their discharge instructions and the next steps they need to take in their recovery.

Hospital care coordinators step in. “Healthcare is complicated,” Dr. Colone notes. “Patients come in and are very overwhelmed, and so are their families. We need a system that is responsive to helping patients and families sort out their next steps. We want them to make the best decisions.”

A future care-coordinators project will address readmission prevention for home-care patients. “That’s big because there are more patients going to home care after discharge than going to a facility,” Dr. Colone says.

Preliminary studies show that the hospital care-coordinators program is having a positive impact. Working with care coordinators, patients who are transferred to skilled-nursing facilities have a hospital readmission rate under 5 percent, Dr. Colone says. A pilot study of the program in primary-care offices also showed impressive results. Patients served by care coordinators had a 29-percent decline in emergency-room use and a 19-percent drop in hospital admission.

“We’re trying to do this in such a way as to measure what we’re doing,” Dr. Rosenthal says. “We have to be able to demonstrate that patients actually end up with better care and at lower costs.”

Meanwhile, primary-care doctors and patients are already praising the UCLA medical-home program’s impact. Fifteen care coordinators are assigned to primary-care offices, with plans to expand soon to another 14 locations.

“There is an astonishing unanimous reaction that care coordinators add benefit,” Hall says of the physicians’ response. “And not only with patient care. Another aim of ours is to improve physician and staff satisfaction. For a physician with a busy schedule to know she has additional resources to help connect with patients is a huge bonus.”

Patients, too, feel like someone is watching their backs.

“One of the goals of the program is to improve the patients’ experience of care,” Dr. Skootsky says. “One of the reasons people like it is they know if they call the office, they can talk to their care coordinator.”

Over time, patients begin to understand the role of the care coordinators and trust them to handle their questions and problems, says Tiffany J. Phan, the care coordinator who worked with Marjorie Crear. “They see the different ways we can assist them, arranging any type of healthcare or social need. I hear more and more from my patients all the time.”

Crear especially enjoys the ease of access, being able to pick up the phone and get Phan on the line. “I used to have to call the doctor’s office when I had a problem, and I had to wait until the doctor had a chance to call me back,” Crear says. “Now I call Tiffany and tell her what’s going on, and she will coordinate between my doctor and me.

My health is improving. There’s someone to help rather than me just being out there by myself.”

Shari Roan covered medicine and healthcare for the Los Angeles Times.


Add a comment

Please note that we are unable to respond to medical questions. For information about health care, or if you need help in choosing a UCLA physician, please contact UCLA Physician Referral Service (PRS) at 1-800-UCLA-MD1 (1-800-825-2631) and ask to speak with a referral nurse. Thank you.