Marjorie Crear suffers from hypertension and diabetes, and is recovering from both a recent stroke and heart attack. The 66-year-old Los Angeles resident lives alone, and as a result of her health problems, is frequently seen in the emergency room at the Ronald Reagan University of California Los Angeles (UCLA) Medical Center. She has been hospitalized numerous times.

One of the most pressing issues in health care today is ensuring that high-risk patients such as Crear continue to maintain good health after they leave the hospital. To achieve this goal, the staff at UCLA launched their Patient Centered Medical Home Program 16 months ago. Currently, the program is operational in 14 UCLA Health primary care practices and employs 19 people, including 15 care coordinators, two clinical advisers, a licensed social worker, and a nurse case manager, who all work together to help high-risk patients navigate the health system and better manage their health. Approximately 15,000 families are currently being served in the program.

“Our program focuses on patients of all ages and demographics who frequently visit the emergency room, are on multiple medications and who are regularly admitted to the hospital,” says Jordan Hall, director of Population Health Management and Comprehensive Care Management for UCLA Medical Group. “A lot can happen in the patient’s home, social and community environment, and our program takes a proactive approach to ensure our patients’ care is coordinated and followed both inside and outside of the hospital.”

Patient Centered Medical Homes (PCMH) aren’t new –they first premiered in the 1960’s as a way to care for special needs children – yet today they are gaining in popularity as more medical groups across the country look at implementing a patient-centered approach, while also improving patient outcomes and lowering costs. Since January 2008, the National Committee on Quality Assurance (NCQA), one of the nation’s arbiters of health care quality, has certified primary care practices that seek to be designated as a PCMH. By utilizing electronic medical records, organizations such as UCLA can now do strategic outreach to high-risk patients, ensuring that those with potentially serious conditions such as diabetes and high blood pressure, get the preventative care they need.

Hall says PCMHs’ were envisioned as a new method of both delivering and financing primary care. The goal is comprehensive care that that is personalized to the patient’s own self-management goals developed in consultation with his or her own physician.

In Crear’s case that means working with UCLA Care Coordinator, Tiffany Phan, who has a masters in public health, to make sure she regularly takes her medications, keeps her appointments, and remains on a consistent medical plan, in order to avoid future trips to the emergency room and costly hospital stays. Care coordinators such as Phan also help patients to access services such as behavioral health, Meals on Wheels and to obtain discounted medications if they are on a fixed income.

“We work to ensure that high-risk patients don’t fall through the cracks,” says Phan, who emphasizes preventative care with patients. Phan and the other care coordinators make it easier for patients such as Crear to have access to health care through greater use of phone calls and e-mails, and regular follow-ups.

“Tiffany 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,” Crear says. “And she calls me frequently to make sure I’m keeping my blood pressure and diabetes in check.”

Nurses are usually care coordinators at PCMHs, but UCLA has hired health professionals from a variety of disciplines to support their efforts. In addition to registered nurses, UCLA has hired social workers as care coordinators and has also made an effort to hire veterans who served as medics in the U.S. military.

Hall says these medics, who have returned from Iraq and Afghanistan, bring a unique set of skills to health care.

“We look at our model of care as a way of enhancing the UCLA health care system and assisting patients who have everything from transportation issues and trouble getting to appointments, to following up with patients at home after they have been discharged from the emergency room,” Hall says.

To date the program has proven to be a success with both patients and physicians and is currently looking to expand by hiring an additional eight to 14 care coordinators.

“We’re continuing to look at how we can provide high-risk patients with traditional services in an innovative way,” Hall says. “When a patient is discharged from the emergency room, a health coach goes to the patient’s home and goes over the discharge instructions, answering any questions they may have about medications or follow-up care.”

Hall attributes the success of the program to the fact they have numerous leveraged services including primary care, pharmacy, behavioral health and social workers all coming together to ensure better patient outcomes. By working together, Hall says the team can troubleshoot issues with patients before and after visits, and to reduce treatment delays and inappropriate emergency room visits.

“Our goal is to help these patients remain in stable health and to prevent them from returning to the hospital even sicker than they were before,” Hall says.