“Interconnected” care makes the difference for one very complex patient

Older African American woman sitting with a white male doctor holding a stethiscope up to her chest

Lung disease. Heart disease. HIV. Depression. Anxiety. 

It’s just an average Wednesday for Orngiel Corbin.

As she waits for her cardiologist to arrive at an exam room at one of MLK Community Healthcare’s outpatient practice sites, Orngiel complains of lightheadedness, stomach upset, anxiety and more. She fingers the portable oxygen pump she takes everywhere and complains that the hot weather is making it more difficult to breathe.

It’s a lot to handle for anyone. Each condition that the 58-year-old resident of South LA suffers from requires one or more medications—a total of 20 in all each day. Orngiel’s treatments require regular doctor’s appointments, home monitoring and more.

On their own, patients with complex conditions like Orngiel are almost always overwhelmed. Remembering to take medication (often several times a day), find and travel to medical specialists, and not lapse into paralyzing depression that could put a stop to recovery, are just some of the challenges.

Fortunately, Orngiel has something in her corner that few vulnerable patients have: a coordinated team of experts, all under one roof, united by the desire to improve her health. In Orngiel’s case, this includes a primary care provider, a cardiologist for her congestive heart failure, a pulmonologist for her emphysema, an infectious disease doctor to manage HIV, an addiction medicine psychiatrist to help her fight a debilitating relationship with cigarettes and alcohol, and a therapist to support her on her healthcare journey.

“If I didn’t have this care team, I’d be dead,” she says simply.

Whole person care

Integrated care is something that all patients need but – especially in underserved areas like South LA—rarely get.  A study in the International Journal of Integrated Care noted that the US has historically lagged in efforts to integrate health and social care compared to other high-income countries resulting in “remarkably poor” outcomes for patients.  Yet research shows that patients who receive care not just for their primary diagnosis but for other health conditions that may impede their recovery are much less likely to be hospitalized. 

It’s why MLKCH has received combined support of more than $1.5 million from Cedars-Sinai and the California Community Foundation to make integrated behavioral health care a routine part of regular, physical health care.  That support has reaped big results; this August, MLKCH received a prestigious three-year accreditation from the National Committee for Quality Assurance (NCQA) for its efforts to ensure that patients in the underserved community of South Los Angeles receive high-quality, coordinated care.

Although Orngiel mourns her former vigor—the South LA resident once loved to camp, snowboard and boat—there is no question that MLKCH’s integrated approach is helping prevent a more precipitous decline.

On a recent Wednesday at MLKCH’s Wilmington Clinic, two different members of Orngiel’s care team—Dr. James Pinney (a cardiologist) and Dr. Maita Kuvhenguhwa (an infectious disease doctor) have good news to report.  Orngiel’s blood pressure, cholesterol, and T-cell numbers are good.  Her kidney function is “better than it has been in many, many months,” according to Kuvhenguhwa. The heart monitor that Pinney gave her to wear at home to check for any dangerous arrhythmia found nothing unusual. “That’s good news,” says Pinney, who now doesn’t have to see her for another six months.

Her progress is only possible because all her doctors sit in the same office, share the same instantly-available electronic health information and can consult a colleague who may be sitting just steps away.

“A team approach seems obvious,” says Pinney. “But it’s actually less common that you’d think. A lot of patients in other health systems have to go one place for primary care, another for specialty care and yet another for tests and medications. When you’re low-income and may not have a car and you feel crummy, this can become a huge obstacle to progress.”

“If I didn’t have this care team, I’d be dead."

Orngiel Corbin

Chain reaction

Orngiel first came to MLKCH in March 2018 for basic primary care. Quickly it became apparent that no physical recovery would be possible unless she received specialty care.  Within a month, she was seeing a MLKCH psychiatrist. Within three months she was seeing Dr. Kuvhenguhwa. From there on the referrals kept coming: podiatry, pulmonology, cardiology, addiction medicine, psychology.

“It was a chain reaction,” Orngiel recalls with a smile. “As they got to know me I ended up with a whole team.”

Aiding in this coordinated care process is a state-of-the-art electronic medical records system that sends out an alert to all of Orngiel’s doctors if there is a change in her care plan. This is especially important where medications are concerned. The efficacy of HIV drugs, for example, can be dampened by other drugs. MLKCH software scans every new prescription and alerts the prescribing doctor if one does not pair well with the others.

“We come into any patient encounter with an integrated care mindset,” says Kuvhenguhwa. “All aspects of care are interconnected. Ignore one and they will all fall apart eventually.”

Staying the course

Keeping Orngiel on track with her self-care is also important. She meets regularly with Dr. Maria Mechure, a psychologist, to receive support and gentle encouragement on her biggest obstacle to health: stopping alcohol use and quitting smoking.

“I have that battle with myself all the time,” Orngiel tells Pinney. “I have to try harder.”

The mind-body connection is a critical part of MLKCH’s therapeutic approach, says Dr. Mechure. 

“If a patient is depressed they might miss an appointment,” Mechure says. “Part of them might be thinking: what’s the point?  [In therapy] we talk about what happens when they don’t go—how they’ll just get sicker. Ultimately it’s about leading patients like Orngiel back to the ultimate goal of feeling well enough to be independent in their life.”

MLKCH tries to help in other ways. Sometimes, transportation is provided to bring her to her appointments. Other visits are scheduled by video to spare her the trip in. At her recent appointment, Dr. Kuvhenguhwa offered a free pill box to Orngiel to help keep her on track with her daily medications. 

“Dr. K is very down to earth. She takes her time with me,” says Orngiel. “She’s kind and explains everything to me.”

At the end of each visit a patient care technician walks her through an organized printout of her medications—what’s new, when to take them, how much to take. He also gives her a printed list of the dates, times and instructions for the eight upcoming visits she has scheduled between now and February 2024.

Ultimately, a lot depends on Orngiel’s desire to heal.  She says she is motivated.

“I want to be there for my grandbaby,” she says. “I love her. I want her to know me and I want to know her.”

Her care team at MLK Community Healthcare are dedicated to making that happen.

Other Tags