Comprehensive Care Coordinators (CCCs) are currently embedded in 30 UCLA primary care offices as a part of the Patient Centered Medical Home (PCMH). They provide coordination of services for high-risk patients to promote the Institute of Healthcare Improvement's Triple Aim - improving the patient experience, improving the health of populations, and reducing healthcare costs.
CCCs work with high-risk patients to reduce preventable hospital/emergency department admissions and over-utilization of services, promote health maintenance and management of chronic diseases. As unlicensed staff, CCCs work closely with Clinical Advisors (RNs and LCSWs), pharmacists, physicians, case managers, and practice managers as key members of the patient's interdisciplinary Care Team. Jointly, they help navigate the complex healthcare system for patients, identify and coordinate resources for on-going care, educate patients on their providers' recommended treatment plan, motivate and monitor follow-through, and identify and resolve any barriers that may interfere with patient's compliance with individualized treatment plan. These interventions promote the provider's plan of care and enhance the patient's engagement with self-care to improve outcomes.