Team Based Care - Orange

Providers (MD, DO, FNP, PA): Dr. Mugabe Walker, MD; Dr. Nuwan Pilapitiya, MD; Ginger Smith, FNP

• Keeps problem list, medication list and patient care plan updated for team members;
• Approves orders and referrals for health maintenance.

Behavioral Health Provider (LCSW, LPC, PhD): Laura Burkhardt, LCSW

• Provides skills training and self-management for behavioral health needs
• Provides screening, interventions, and referrals to ongoing mental health treatment
• Assists patients with identifying and accessing clinical/community services and resources
• Provides counseling and facilitates support groups for patients living with chronic conditions
• Provides expert consultation and supports the work of the primary care teams.

Primary Nurses (MA, LPN): Lynn Gubernard, MA; Tamara Valdez, MA; Kimberly Roybal, MA, Tina Tudor, LPN

• Patient Rooming, taking vitals, discussing patient history
• Completing preventative care vaccinations, orders, and screenings
• Active in patient education, goal setting, self-management, teaching, and coaching;
• Medication reconciliation and education;

Prescription Refill Nurse (LPN, RN): Terese Sowards, LPN

• Completes all requests for medication refills
• Ensures authorizations in place for all medications
• Communicates with patients and pharmacies regarding medications

Authorizations Nurse (MA): Elishia Melgares, MA

• Completes all authorizations for referred medical procedures
• Works with specialists to ensure completed documentation
• Works with patients to ensure completion of referred procedures

Care Coordinators: Valerie Atencio, Charity Hancock, Rachel Dooley

• Follows up with patients following Emergency Department and Hospital visits to ensure all needs met and help patient access primary care
• Guides patients through the complexities of the healthcare system
• Answers questions and address patient/family concerns
• Educates and supports patients with better understanding of their condition/disease processes and empower to make informed treatment decisions including treatment options
• Provides assistance with financial concerns, schedules appointments/tests/therapies, finds resources during and after treatment, arranges transportation to medical/psychosocial appointments
• Assists providers and staff in identification of patients with complex needs and those requiring extra assistance

Medical Office Assistant: Taylor Madril

• Provides administrative support to care team.
• Contacts patients for negative test results, scheduling needs, and other pre-visit coordination