Extensivist program helps high-risk patients manage health and avoid hospitalization

Story highlights

• Launched in July 2017, the UCLA Health Extensivist Program(Link opens in new window) provides care for more than 400 complex patients.
• The program is set to expand to UCLA Medical Center, Santa Monica(Link opens in new window) and outlying communities in 2019.

A new program launched last year by the UCLA Department of Medicine is helping patients at high risk for hospitalization better manage their health and avoid unnecessary hospital stays. “The extensivist program provides a primary care medical home for patients with complex medical conditions, such as congestive heart failure, chronic kidney disease, cerebrovascular disease and a history of organ transplantation. These patients often need intensive outpatient services to optimally manage their health,” says Sun Yoo, MD(Link opens in new window), medical director of the UCLA Health Extensivist Program.

An interdisciplinary team of experts provides patient care at an extensivist clinic located in the internal medicine suites at Ronald Reagan UCLA Medical Center(Link opens in new window). The clinic offers same-day appointments and provides services such as treatment with intravenous fluids for dehydration, antibiotics for infection and symptom management. The team comprises internal medicine physician extensivists and nurses, as well as a care coordinator, pharmacist, social worker and patient service representative. Together, they provide health services, coordinate appointments for tests and with specialists, connect patients to home health services, and help patients navigate the health system.

In July 2018, Andrew Shubov, MD(Link opens in new window), and Annie Zhang, MD(Link opens in new window), specialists from the UCLA Center for East-West Medicine, joined the extensivist program. These physicians provide expertise in integrative treatments including acupuncture, mind-body practices and trigger-point injections for pain relief.

The extensivist team meets weekly to develop, review and modify patients’ comprehensive care plans. Four extensivists, including Dr. Yoo, have provided care to more than 400 complex patients at the Westwood location. This number is expected to increase to 1,000 patients next year. “We have a wait list of patients and will be expanding the program to UCLA Medical Center, Santa Monica and surrounding communities in 2019,” says Dr. Yoo.

Back row, from left: Kevin Noel, William Carroll, MD, Andrew Weber, MD, Jesus Valdez and Darcie Miller; front row: Yihan Chen, MD, Sun Yoo, MD, and Varsenik Papazyan-Gutierrez.

Extensivists see patients in the outpatient clinic as well, helping them regain their strength and health by identifying issues before they become serious problems. To participate in the program, patients must see a UCLA Health provider, have a chronic health condition and have been hospitalized two or more times during a 12-month period.