UCSF Care Support Service
The UCSF Care Support Service provides hospital transition support and ongoing intensive care management for medically
complex adult patients who have UCSF primary care providers at the Division of General Internal Medicine Clinic
(DGIM), Family Medicine Center at Lakeshore or UCSF Center for Geriatric Care.
Our role is to complement primary care by partnering with the primary care providers to support our most medically complex patients. Our partnership will provide comprehensive patient-centered support across the spectrum of care to bring patients to their highest level of wellness possible.
The Care Support teams embedded in the primary care clinics are:
Family Medicine Center at Lakeshore & UCSF Center for Geriatric Care
Erika Tunick, MSW and Robin Andersen, NP
Division of General Internal Medicine (DGIM)
Lisa Sapiro, LCSW and Anne Thibault, NP
- Improving the functional status and quality of life of our patients
- Promoting the appropriate utilization of medical resources
- Supporting the primary care providers and improving provider satisfaction
Key Components of Care Support
- A comprehensive initial in-home assessment by the nurse practitioner and social worker.
- Weekly team case conference with an interdisciplinary team (geriatrician, psychologist, pharmacist, social workers, nurse practitioner) for care planning.
- Primary care physician reviews and provides input on the careplan to the Nurse Practitioner/Social Worker
- A follow-up home or clinic visit to review and then initiate the care plan with the patient and family.
- Ongoing intensive care management based on the care plan including medication reconciliation, care coordination, social support, linkages to community resources, education on self-management skills including self-monitoring for seeking medical attention. Follow-up will take place in the clinic, by telephone or in the home as needed.
Care Support Focus
- Transitions of care
- Chronic care & medication self management
- Substance abuse
- Chronic pain
- Mental Health issues
- Dementia/Cognitive Status
- Geriatric conditions
- Nutrition/Weight issues
- Caregiver support
- Social Service coordination
- Advanced care planning