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My Summer with Care Connect

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a student examining a patient
Taking care of patients with complex needs through an interdisciplinary approach.
Photo: Elisabeth Fall

By Zoe Kornberg, MS2

*Note: Patient-identifying information has been changed to protect patient confidentiality.

This summer as part of the UCSF Primary Care Leadership Academy, I spent six weeks precepting at a county-run primary care practice in Richmond called Care Connect. This practice is solely dedicated to patients who are characterized as super-utilizers—those who use a disproportionate amount of health care resources with frequent hospitalizations and emergency department visits. By virtue of being invited into the program, our patients are very sick—half have a substance use disorder, half have diabetes, a third have heart failure, and a quarter are on dialysis. Our small team—consisting of physicians, nurse case managers, clinic nurses, an alcohol and drug counselor, a social worker, a community health worker, and a housing specialist—devotes itself to a panel of fewer than one hundred patients.

All Roads Lead to Organ Failure

Dr. William Osler said, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

The patients and the interdisciplinary way in which we treat them at Care Connect reminds me of that quote every day. For example, we have three female patients with heart failure and end-stage renal disease. If I only look at their medications and problem lists, it might seem like these three women need the same care; however, the true solutions to their problems are not at all similar.

  • The first woman is in her thirties and has a history of severe autoimmune disease. Several years ago she received a kidney transplant under a subset of Medicaid for gravely ill undocumented immigrants. The coverage ended a year after her transplant and she could not afford the anti-rejection medications. Her body rejected the new kidney and she is back on dialysis, most likely for the rest of her life. A pathway to legal immigration status would have spared her this suffering and humiliation and continues to be her primary goal of care.

  • The second woman is in her sixties and in the end stage of Type II diabetes. Restoring her sight and bowel function and controlling her pain would significantly improve her quality of life.

  • The third woman’s heart and kidney failure results from the complications of a twenty-five year addiction to methamphetamine. In her current state, she is not stable enough to be moved to private housing—likely the most important step on her path to safety and sobriety.

The richness of the parallels and differences among their stories embody the tremendous challenge of primary care. Through these patients, I came to a deeper, more real understanding of this challenge.


Goals of Care: the North Star of Primary Care

Even though the overall goal of the program is to keep patients out of the hospital and emergency department, it was frequently inevitable. Therefore, the new goal was to learn what precipitates a hospitalization for that particular patient and to understand what the necessary steps will be to prevent the next one. Two patients with substance use disorders come to mind.

  • The first has a problem with alcohol. She manages to stay sober for a few months before relapsing. She binges with his friends at bars and house parties until her sponsor finds her and calls 911. While our counselors provide her with therapy during her sober periods, it is seemingly inevitable that she falls into the same cycle. Since joining Care Connect, the time between binges has gotten longer and the number of days spent in the hospital fewer. With each run through the routine, we help her weaken the triggers of the vicious cycle she has been stuck in for so long.

  • The second patient is a young man with heart failure, methamphetamine use, schizophrenia, and osteomyelitis of his right leg (a bone infection). Due to his distrust of medical professionals, long history of incarceration and trauma, and paranoid delusions, he leaves the hospital long before the antibiotics have cured the infection in his leg. As a result, he ends up back in the emergency department every couple weeks. While a long hospitalization would look bad in our quarterly reports, it would be better for the patient to complete the course of antibiotics and stay in the hospital.

Care Connect, and ultimately comprehensive primary care, is not really about keeping people out of the hospital. It’s about delivering highly customized care that takes into consideration a patient’s medical, social, and behavioral needs. With the patient’s goals of care as their North Star, the primary care team has to work together to repair the damage on every side and steer the patient back on course.

I would like to thank the David Vanderryn Memorial Fund Summer Preceptorship Program and UCSF Primary Care Leadership Academy for generously sponsoring my summer project and to my preceptor Sara Levin, MD for her mentorship, expertise and tremendous compassion.