UCLA Health’s Extensivist Program is improving the quality of life and reducing preventable hospital admissions among patients with complex medical conditions through a multidisciplinary, collaborative and proactive approach to their health care.
Vital Signs spoke with Sun Yoo, MD, MPH, medical director of the three-year-old program, about this emerging model of managing a vulnerable patient population.
For patients with one or more chronic conditions that require multiple specialists and place them at risk for frequent hospitalization, we thought it would be important to establish a medical home and a team of physicians, nurses, social workers, pharmacists, care coordinators and patientservice representatives who would work with primary care doctors and specialists to navigate and optimize care across all settings — outpatient, hospital, skilled nursing facility and home. Ours is among the only programs of its kind that is based in the outpatient setting in a large academic health system; it has expanded as the value of a team approach has become clear, from one extensivist physician when the program was launched in 2017 to eight primary extensivist physicians by July 2020 working at UCLA facilities in both Westwood and Santa Monica.
We enroll patients with conditions such as congestive heart failure, cancer, diabetes, prior stroke, complex neurologic or rheumatologic conditions and a history of solid-organ transplantation — many of whom have more than one chronic condition that further complicates their care. Patients who have been admitted to the hospital two or more times in the previous year are strong candidates to benefit from the extensivist approach. It’s very helpful for this complex and vulnerable population to have a robust, multidisciplinary team that can work together to develop a comprehensive plan, coordinate when they see their providers and work with the subspecialists they need. We also help to ensure smooth transitions of care.When patients are admitted to the hospital, they are seen by different teams, and then they return to their primary care doctor after they are discharged. Those transitions can be vulnerable periods for patients, with the potential for delays or miscommunications. Having the same doctors follow them in all settings is designed to make sure the care is well coordinated.
Patients who are referred to the UCLA Extensivist Program — typically by primary care physicians or hospital-based subspecialists, or after being identified as high-risk for hospital admission by UCLA’s population-health group — receive a comprehensive evaluation by the team, which meets regularly to discuss and devise care plans for patients, with input from their subspecialist physicians. We look at the medications they’re taking to determine whether any are no longer needed. We can track patients at home with remote monitoring devices to ensure, for example, that their blood pressure isn’t elevated.
We address their quality of life through education and counseling about nutrition and exercise, physical therapy, and assistance in navigating the health system so that they get the care they need at the time they need it. The program’s nurses are in regular contact with patients, and an extensivist nurse practitioner makes visits to patients at home and in nursing facilities. It’s a much more coordinated, proactive approach to their care.
Preliminary evidence of the first 150 patients enrolled in the UCLA Extensivist Program found a 69 percent decrease in hospitalizations and a 67 percent decrease in emergency department visits when comparing their experience in the six months prior to their enrollment with their first six months in the program. Program evaluation is still ongoing. A significant advantage is that each extensivist physician has a smaller panel, which allows us to spend the time to build relationships and really get to know them. In doing so, we are not only coordinating their care comprehensively, but looking at each individual holistically to address the medical, behavioral and social components that affect their health.