The Complex Care Team (CCT) is a multidisciplinary team dedicated to coordinating the care of the most challenging surgical patients within the UCLA Health system. Ample evidence shows that the most resources and costs are consumed in the care of the 20 percent of patients with the most complex problems.
UCLA has assembled a team with experience from surgery, nursing, anesthesia, critical care, acute pain, and perioperative medicine to:
- Identify complex patients in advance of surgery;
- Optimize their medical condition prior to surgery
- Coordinate their care – in the operating room, during post-anesthesia care, and in the wards and ICUs.
We provide a highly coordinated and seamless patient experience, with personalized perioperative advanced planning, and high-fidelity communication between perioperative anesthesiologists, surgeons, and consulting physicians. Ultimately our goal is to investigate root causes for patient delays, cancellations, and unplanned ICU admissions. We study morbidity and mortality from the perspectives of underlying patient illness and procedural complications. Armed with this information, we have developed standard protocols for preoperative workup. On a daily basis, we adjust scheduling of cases by acuity, designate day-of-surgery providers, and generate clear perioperative plans.
The surgeon and our nurse navigator identify surgical candidates who are likely to require care coordination for their upcoming operations. Their charts are reviewed by anesthesiologists and critical care intensivists with lead time to organize sub-specialty consults, workup, prehabilitation, and physiological optimization prior to the scheduled surgery. We specifically personalize the coordinated consult using a combination of telemedicine, in-person consultation, and directed communication with the patient’s own primary physicians and subspecialists.
We also coordinate with our in-house specialists who will follow the patient during the acute recovery period. We have a dedicated team to follow these complex patients and ensure that recovery milestones are met throughout the recovery period. After discharge, the Complex Care Team follows the patient’s progress into rehabilitation and the home environment, and then works directly with our informatics team to analyze outcomes, constantly improving our process and patient experience.
To learn more about our team's process, read this story of a recent collaboration on one of our most complex cases.