CHICAGO -- UCLA takes care coordination very seriously. Care coordination is a major part of the provider organization’s population health program. And a major part of the care coordination effort is unlicensed care coordinators.

UCLA has 30 unlicensed care coordinators embedded in its care sites. They are the front-line staff in population health and they are supported by registered nurses, licensed social workers and pharmacists. These healthcare workers support all of the health system’s primary care sites and some specialty care sites.

The team effort surrounding the unlicensed care coordinators is called the Primary Care Innovation Model. There’s even a flag in the organization’s Epic EHR that indicates which patients are part of the model and have access to related resources, including the coordinators.

"They [health navigators] work on patient advocacy and linkage to resources, and they really deliver care, taking a minute to understand social determinants of health by asking questions and developing relationships with patients."

Joyce Komori, UCLA

“Unlicensed health navigators are in the offices that they support,” said Joyce Komori, director of comprehensive care coordination for population health management at UCLA. “They are an extension of the provider. They go through a 6- to 8-week training program, including e-learning. They are measured on their ability to prevent unnecessary emergency department admissions and hospitalizations.”

These healthcare workers focus on high-urgency issues for high-risk, high-utilizer patients. They are trained on how to deal with the unusual.

“Core strategies include identifying high-risk issues using analytics tools,” Komori said. “They also work on things like health system navigation. A provider puts in a referral for neurology and our team works on getting the patient to the right caregiver as soon as possible. They work on patient advocacy and linkage to resources, and they really deliver care, taking a minute to understand social determinants of health by asking questions and developing relationships with patients.”

Komori called her 30 unlicensed care coordinators a specialized SWAT team. And she said when a patient’s healthcare journey is touched by a comprehensive care coordinator, “that meaningfully impacts patients’ care, reducing the overall cost to our at-risk programs.”

Komori addressed the HIMSS and Healthcare IT News Pop Health Forum Tuesday during a session entitled “Unlicensed Staff Plays Key Role in Reducing Emergency Department Visits Big-Time.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

 Read our coverage of HIMSS Pop Health Forum in Chicago.
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