This story is from UCLA Today, a discontinued print and web publication.

Guiding patients with complex problems through health care system

Marjorie Crear, 66, lives alone and suffers from hypertension and diabetes with complications. She is recovering from a recent stroke and a heart attack. The Los Angeles resident shows up often in the UCLA Emergency Department and has been frequently hospitalized.
In an effort to get Crear on a healthier path, she was assigned last November to a UCLA comprehensive care coordinator. The coordinator is working to ensure Crear takes her medications, keeps her appointments and remains on a consistent plan designed by her primary care physician and care team — including multiple specialists — so she can hopefully avoid further trips to the emergency room and costly hospitalizations.
Care coordinator Tiffany Phan (left) helps Marjorie Crear sort through her many appointments and doctors' instructions. She's also helping Crear find an apartment that's better suited to her limitations.
Care coordinator Tiffany Phan, who has a master’s in public health, is also working on arranging more suitable housing for Crear. Phan is helping to move her out of her current Section 8 apartment to a different unit that can better accommodate the limitations she encounters in daily living.
"We try to make sure high-risk patients don’t fall through the cracks," said Phan, who is assigned patients based on how complex their health problems are. "These patients need a little extra attention."
Patients with high-risk factors are most frequently assigned to care coordinators through patient registries, post-discharge reporting from the emergency department and hospital, and by primary care providers.
For Crear, Phan may prove to be a life saver — literally.
Crear said that after her heart attack on June 3 and the stroke that followed on Sept. 30, she had trouble keeping all her various medications in order and remembering to take them at the prescribed times. Phan visited with her multiple times in the clinic to set her on the right path.
Said Crear: "She printed out a list of all my medications and helped me get straight which ones to take at what times. That really helped because sometimes I get a little confused, and I feel a little sick if I take the pills too close together." Phan also calls her to remind her to take medications to keep her blood pressure and diabetes in check.
The program, Crear said, has been "very helpful. I can call Tiffany, in addition to calling the doctor for everything. I’ve never had as much help before as I get with this program."
The Patient Centered Medical Home Program, which fosters the comprehensive care coordinators, was launched about 16 months ago and currently employs 19 people — 15 care coordinators, two clinical advisers, a licensed clinical social worker and a nurse case manager. Their task is to help navigate high-risk patients like Crear inside and outside of the health system. Through planned interventions, care coordinators guide patients through what can be a confusing health care system, particularly for those with multiple health problems and all the additional physicians, specialists and appointments that entails. 
Care coordinators also help patients access other services such as behavioral health and Meals on Wheels; they can arrange for transportation to and from appointments as well as work with pharmaceutical companies to get discounted prescriptions for low-income patients. They can also help patients who may have limited health coverage, or none at all, to enroll in programs such as Medi-cal and Medicare.
If necessary, care coordinators will sit in on physician appointments to make sure patients leave the doctor's office with a clear knowledge of their care plan.
The program is designed to assist UCLA primary care physicians with their complex patient panels. Many of these primary care physicians were performing these tasks themselves, aimed at preventing costly visits to the emergency room and expensive hospitalizations, said Jordan Hall who oversees the program as director of public health management and medical home care coordination.
Care coordinators are available at 14 UCLA Health primary care practices, many with high numbers of geriatric patients.
"We target patients with high utilization of emergency department services and who have been admitted into the hospital multiple times," Hall said, and are at high risk of returning there. "Our goal is to provide care coordination services to these fragile patients in varying acuity levels with the goal of helping them transition to healthy care plans. This includes making regular contact with patients and becoming a consistent resource in their care team."
The program is operational in 14 UCLA Health primary care practices, Hall said. Many of these practices have high numbers of geriatric patients, who often have the most acute problems. Working together, care coordinators and physicians put patients on a healthy path when possible and ultimately place patients on care plans that lead to the highest functional status and quality of life.
"We want to provide them with the right tools to prevent them from coming back to the hospital even sicker than they were before," Hall said.
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