Published : Tuesday, February 20, 2018 | 3:03 PM
The generous grant award provided to ChapCare will support the organization’s Care Coordination program, in which high-risk, high-cost patients with chronic health issues receive systemic coordination of their general and behavioral healthcare for improved outcomes.
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ChapCare began providing Care Coordination services in January 2017 when it hired a Care Coordinator to work as part of its Diabetes Team – Care Coordination Model. This model utilizes a care team to manage homeless patients with uncontrolled diabetes, in partnership with Union Station Homeless Services in Pasadena, a leading human services agency in the San Gabriel Valley.
Since then ChapCare has hired a second Care Coordinator to address at-risk patients within its network, specifically non-homeless individuals with diabetes, patients with hypertension and/or coronary artery disease, patients with co-morbidities (i.e. multiple chronic health issues), and high-utilizers of ChapCare’s and other healthcare services (i.e. hospitals, etc.).
“Access to Care Coordination services is critical for our most at-risk patients,” said Margaret B. Martinez MPH, ChapCare’s Chief Executive Officer. “The Care Coordinator gets to know the patient on a personal level, works with the patient to identify their health goals, and coordinates services to help them meet those goals.”
A patient who has benefitted from ChapCare’s Care Coordination services is Victor C., a 57 year-old diabetic client who had been living on the streets for 8 years. When Victor was first assigned to the Care Coordinator, he was in the care of ChapCare’s Associate Medical Director, Dr. Paul Gailiunas.
In 2016, a portion of Victor’s left foot was amputated at LAC+USC Medical Center, due to a diabetes-induced ulcer. The Care Coordinator began providing Victor with daily reminders to take his medication and test his blood sugar, counseling him along the way on the importance of learning to manage his own care. She also took him to his podiatry appointments.
His blood sugar, once in the 300 – 400 range, has now stabilized within a controlled range of 100 – 120. A ChapCare podiatrist has joined Victor’s care team. In April, after two-years on a housing waiting list, Victor entered permanent supportive housing. The Care Coordinator now only conducts once-monthly check-ins with him because he no longer needs regular reminders to take his medication and test his blood sugar. His care team anticipates that the ulcer on his left foot will be completely healed within the next few months.
Community Health Alliance of Pasadena (ChapCare) was founded in 1995 by a group of community residents, city officials, and health care agencies to establish primary healthcare services for low-income, uninsured residents in the Pasadena area. ChapCare began providing medical services in 1998 and dental services in 2001. Today, ChapCare is a network of HRSA-funded community health centers that provides healthcare services to countless insured, under-insured, and uninsured residents of the San Gabriel Valley. ChapCare operates 4 health centers in Pasadena, 1 health center in Monrovia, and 3 health centers in El Monte/South El Monte. ChapCare provides over 64,000 primary healthcare visits annually to over 15,000 unduplicated patients.
For more information on ChapCare and its services, please call (626)-398-6300 or visit www.chapcare.org.