"As a clinician, my strategic and scholarly focus is on testing better system designs to reliably deliver the 4 Pillars of Primary Care (Personal Relationship over time, Access to the right care/right time, Comprehensive Care, and Well-Coordinated Care) to individuals and communities. In my work I have tested the application of the Model for Improvement from the Institute of Healthcare Improvement to the transformation of primary care practices into value producing Patient Centered Medical Homes (capable of the reliable delivery of the 4 Pillars).
The promotion of wellness for the defined communities served by primary care practices requires the leveraging of the best evidence on population-based care delivery by experienced clinician-scholars dedicated to the care of defined populations across the life cycle. This work must be supported by the development of innovative informatics to provide useful information to providers, patients, and administrators while minimizing cognitive workload.
As a teacher and clinician I have 30 years of experience caring for vulnerable populations. I have developed survey instruments to provide care teams with data on what I describe as the four domains of wellness- Behavioral Health (including Social Determinants), Oral Health, Fitness/Nutrition/Rehabilitation and Medical. This data animates dashboards designed to reduce the cognitive work required to reliably recognize the impact of multiple determinants on the well-being of each patient. Further, these dashboards will communicate dynamic changes in wellness and outcomes resulting from planned interventions, providing both monitoring and static outcomes measurement functionality. It is my hope that these metrics may support payment for value, which is the only economic path toward financially sustainable medical homes and integrated health networks.
For the coming year, my professional priorities are to continuously improve the way we practice and teach population-based and family-centered care across the life-cycle within the UCLA Health Network. Most of my practice-based research will take place within The Watts Health Center in South Los Angeles, where I will continue to serve vulnerable populations through direct patient care, teaching, and translational research."