Community Health Alliance of Pasadena ChapCare has been awarded $25,000 by CIT Bank N.A., the parent company of Southern California’s One West Bank. 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. CIT has a longstanding commitment to social responsibility and corporate citizenship, exemplified by its support of a diverse range of non-profits.
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.
