As an internist and geriatrician at California Pacific Medical Center (CPMC), Dr. Wendy Zachary often thought about ways to improve the hospital discharge process and the healthcare people received after their return home. Will patients follow discharge instructions? Take medications as prescribed? She worried about ongoing health issues that could spiral into a health crisis, leading to hospital readmission and, for older adults, possible loss of independence. So, when On Lok approached her to participate in the pilot for a new program that could support her patients on their healing journey, Dr. Zachary was ready to try a different approach. Its initial results have exceeded all her expectations.
“On Lok Connected Care (OLCC) is like a warm handoff,” said Dr. Zachary. “Patients receive a personalized plan that includes care coordination, stress management, and strategies to help them reach their health goals. This helps preserve the dignity of the individual and decrease readmissions for problems that could have easily been clarified or supported by the health coach.”
According to the UCSF Center for Excellence in Primary Care, half of patients leave medical visits without understanding the clinicians’ advice and only 10 percent are involved in their health decisions. Health coaching can help at-risk individuals build the knowledge, skills, and confidence they need to take charge of their health and improve their outcomes.
“OLCC is a new model of engagement and prevention to support and respond to the needs of the whole person as they age,” said Diana Yin, On Lok’s Chief Strategy and Analytics Officer. “It brings the values and features of On Lok PACE, like high-touch personalized care and complex care management, to a population that isn’t necessarily eligible for PACE. At the same time, we bring the practice of health coaching to a medically complex population, which is unusual but fits our belief that everyone has potential for quality of life. This pilot will show whether these ideas can make a difference in someone’s life.”
“On Lok Connected Care is different and innovative because it combines care management with compassionate guidance to help participants adopt healthy behaviors that become lifelong habits. Participant and Coach Care Specialist become partners in the patient’s journey to better health and well-being,” said Andrea Rubin, Coach Care Specialist and Sr. Project Manager with OLCC.
“We find and help participants utilize community resources for daily living, such as home care, meal deliveries, and transportation. We coordinate medical appointments, assist with medication reminders and refills, and can serve as a cultural bridge between participant, family members, and the medical team, if needed. We also help with applications for utility bill waivers, food stamps, and other services,” said OLCC Coach Care Specialist Shirley Hoang.
During interdisciplinary rounds at CPMC, Ms. Hoang works with Dr. Zachary to identify candidates for the program: patients usually 70 years or older who are at risk for readmission and complications.
Marty Carls has been in OLCC for about six months. A long-term survivor of HIV, he was referred by a good friend who was very happy with the program. “Working with my coach has been a phenomenal experience,” said Mr. Carls. “She has connected me to the resources I need to continue flourishing and assisted me with prevention and screenings. I feel absolutely comfortable talking to her. With her help, I have applied for a rent subsidy program and decluttered my home, so now I live in a safer environment. During the pandemic, she made house calls, so I felt less isolated.” At 79, Mr. Carls said he is doing extremely well. “I live alone and advocate for myself. I feel 100 percent more supported with OLCC. I highly recommend the program and I am planning to stay in it for as long as I can.”
OLCC’s high-touch experience is enabled by a highly interactive care coordination platform. When first designing the program, On Lok aimed to integrate technology as if it were another staff person. “We looked for a tool that could be put to work to provide insights that would help us better deliver care,” said Ms. Yin. When the team found Care3, they also found an enthusiastic technology partner that would grow with the program’s needs.
“We love working with On Lok because they are always challenging us to improve what we do,” said Care3 Founder and CEO David Williams. Care3 allows the team to document each participant’s ongoing clinical experiences; daily care tasks and activities, including medication adherence and symptoms; and interactions between participant, coach and providers. “Data is analyzed and shared over time, generating an evolving ‘picture’ that drives coaches, patient literacy and better care decisions,” said Mr. Williams. “The insights allow the program to track individual progress toward health goals and to have more visibility into the care actually delivered."
Dr. Zachary said OLCC is a terrific partner for at-risk seniors and CPMC. “On Lok has been very forward-thinking in its vision for this program. In the future, we are going to have a huge number of elderly patients that we are not prepared to support. I hope OLCC will continue to grow and be replicated to other medical campuses.”
In the photo, On Lok Connected Care participant Rosemary Williams with her children, James Williams and Linda Williams, who have also enrolled in the program.
For additional information about On Lok Connected Care, visit the On Lok Connected Care web page.