Currently, 7% of high risk patients consume 81% of the total health care costs. Programs like complex care management help improve patient health outcomes and reduce costs. Additional funds can be used to support and create more preventative care programs. What follows is an example of what happens when care coordination and collaboration between complex care and primary care works successfully. 

Gladys Preciado Ramirez remembers being seven-years-old trying to translate for her Spanish-speaking parents at a doctor’s office. It is difficult for a child to translate health information from a doctor and she remembers being incredibly frustrated. This experience led her to become a community health outreach worker on the complex care team for Alameda Health System.

“I’m a patient advocate. I basically serve as a bridge between the patient and provider,” said Ramirez. “I do what I can to make sure my patients stay healthy, whether it’s accompanying them to appointments, or connecting them to other resources.”

Complex Care

Complex care management helps patients with multiple chronic illnesses who are significantly impacted by social determinants of health. As part of PRIME the ambulatory and care management teams are working together to coordinate the care of patients with complex conditions and who are high utilizers of resources to ensure they receive the right care at the right time and in an efficient manner. To support this coordination patients are assigned a community health outreach worker.

“At AHS we care for very high risk patients and they require care coordination across multiple specialties as well as primary care. The aim is to reduce costs through monitoring over utilization of hospital services as well as emergency care. We link patients to community resources to better manage their health,” said Sheila Lyzwa, RN, vice president of care management at AHS.

Currently at AHS the complex care management program is assigned to the primary care wellness centers that serve as the patients’ medical home. The team consists of case managers, nurses, social workers and community health outreach workers. These staff members are embedded in the clinics and work with the providers.


Ramirez, recently helped Anthony “Tony” Pastorino who was suffering from diabetes, high cholesterol, high blood pressure and cirrhosis. Due to his condition, there were many times where Tony and his family had to either call 9-1-1 for help or rush him to the emergency room. He was also suffering from ascites or fluid accumulation in the belly area, which lead to his stomach being drained on more than one occasion.

“When I first met Tony he brought his sisters with him because he wasn’t able to fully care for himself. When the liver functions normally it filters out toxins and waste like ammonia, but when it doesn’t, it can cause problems like confusion and dizziness.”

Pastorino was constantly forgetting things and falling from lack of balance. He had trouble walking because his legs were so swollen and he didn’t remember to take his medication used to treat complications of liver disease, specifically, dizziness and memory loss. Pastorino’s primary care physician, Robert Lake, M.D., connected Pastorino and his sisters to Ramirez and the complex care team.

“There were many times where I had to drive to Tony’s house and check on him because he wouldn’t answer the phone. This really scared me because we were told he could easily go into a coma,” said Debbie, Pastorino’s sister.

“When Dr. Lake told us about the complex care program, I thought anything that will help us will be welcomed. We met with the team and they were amazing. They always showed up and followed through with everything. If we had a question or needed an appointment we would reach out to Gladys and she would take care of it.”


Ramirez and the nurse on the complex care team at Hayward Wellness, went to Pastorino’s house for a meet and greet. They also came up with a solution to help him remember to take his medication.

“We used the resources we had available to us, we used sterile urine cups and a cookie sheet from Tony’s home and created a medication reminder system for him,” said Ramirez. “We showed Tony and Debbie how to use the system and they would pour out the medication for the week and when he would see it, it was a visual reminder to drink his meds. This was a huge win for him. His memory became better and he wasn’t falling.”

While Pastorino finally got his medication adherence under control, he still needed a new liver. His mental status improved, but the overall physical condition of his body was continuing to decline. Lake referred Pastorino to the gastroenterology team at Highland, who then referred him to UCSF for a liver transplant. The complex care team accompanied Pastorino to UCSF for his screening.

“It was important for us to be present at his liver transplant evaluation in San Francisco because we wanted to show the transplant team that we would be there for Tony throughout the whole process. We wanted them to know he would get the care he needs,” said Ramirez.

For a person to be selected as a viable liver transplant candidate several factors are taken into consideration including ability to adhere to a strict medical regimen that prevent organ rejection and a candidates support system. He received a transplant within two weeks of his initial evaluation.

“Gladys took care of me. She reminded me of all my appointments and told me she would be there and she was. She even traveled from Hayward to San Francisco multiple times to meet with me and the UCSF medical team. She would ask questions I forgot. She had everything written down,” said Pastorino.

“I am so grateful for Dr. Lake and Gladys. Dr. Lake stayed on top of my medical care and Gladys constantly checked on me, she even convinced me to get the transplant. I was afraid. I didn’t know if I wanted to have the surgery, but she talked me through it and I am glad I did it. I feel so much better. I lost 100 pounds. She even has me going to a nutritionist now!”

Ramirez says it has been a great honor to support Pastorino and his family. “I love my job. It is very rewarding to know that I contributed to someone’s longevity.”