Advancing Systems of Care
Mary W. Zavala, LCSW, MPP, MA
A social worker at heart, Mary's core commitment is to improving patient outcomes.
Her experience unites the principles of holistic patient-centered care, integration of interdisciplinary teams, data and quality, and continuous improvement.
10,000+
Individuals Served
Under Mary's direction, various programs have delivered high-quality care to more than 10,000 individuals across California.
Multiple
Care Settings
Statewide programs, community hospitals, clinics, and managed care are some of the care environments where Mary has made contributions.
20+
Years of Experience
Mary's experience spans more than 20 years, including direct clinical practice, program development and administration, oversight, and quality improvement.
Experience, Presentations, and Publications
Responsible for all components of implementation, expansion, operations, and outcomes of Enhanced Care Management (ECM) and Community Supports (CS) for San Francisco’s local initiative health plan. Accomplishments include tripling ECM provider network and capacity, doubling member enrollment, implementation of training and technical assistance offerings, and development of quality-of-care standards and oversight process. CS accomplishments include development of ambitious CS service launch timeline resulting in quadrupling of available services, including development of internal infrastructure, a provider network, service delivery structure, and connections between CS services and ECM.
Responsible for all elements of implementation, operations and outcomes Enhanced Care Management (ECM), within the nation’s largest publicly operated Health Plan. Accomplishments include a successful transition of more than 18,000 Medi-Cal beneficiaries into the benefit, establishment a robust network of community-based providers, and participation at State and County levels to drive policy development.
Also responsible for all aspects of Health Homes program development, implementation, operations, and outcomes. Key successes include evidence of improvements in key performance indicators, including decreases in high cost utilization, increases in PCP visits, and sustained member engagement, among this high acuity and high need population of Medi-Cal beneficiaries.
Multi-Organ Transplant Center, St. Vincent Medical Center
Leader tasked with responsibility for ongoing operations of the Transplant Center’s QAPI program, including development of QAPI projects, data and outcomes tracking, and regulatory compliance. Key accomplishments include leadership through CMS’ Transplant Survey, participation in a national performance improvement initiative through the United Network for Organ Sharing, and the opportunity to showcase successes at national conferences.
Clinical Social Worker responsible for assessment and management of kidney and pancreas transplant recipients and living kidney donors.
Department of Urology, University of California Los Angeles
Improving Access, Counseling and Treatment for Californians with Prostate Cancer (IMPACT)
Leader responsible for day-to-day program operations, including clinical, financial, provider contracting, patient outreach and eligibility. Key accomplishments include presentation and publication of peer-reviewed research analyzing enrollee outcomes and showcasing program successes.
Children’s Hospital Los Angeles
Clinical Social Worker responsible for assessment and management of pediatric kidney transplant recipients. Key accomplishments include cross functional partnership to develop transition initiative for pediatric transplant recipients moving to adult care, service as sole social worker on CHLA Institutional Review Board (IRB), and leading regional transplant social work continuing education symposium.
Select Presentations and Publications
Care Management for Healthy Transitions: Building a Bridge to the Community. Panelist, Safety and Justice Challenge California Network, CalAIM Justice Involved Convening, October 24, 2023.
Outreach and Engagement for Enhanced Care Management. Presenter, DHCS CalAIM Enhanced Care Management and Community Supports Office Hours, September 1, 2022.
Enhanced Care Management Members: Supporting Grandfathered Members from Health Homes and Whole Person Care. Presenter, ECM Bootcamp: A Practical Approach to ECM Benefit provided by Los Angeles Managed Care Plans with support from Health Management Associates, Los Angeles, CA, December 2021.
Enhanced Care Management & Community Supports. Co-presenter, Forecasting for the Future: Preparing for Policy and Finance Changes, 2021 Quality Improvement Summit Series, Los Angeles, CA, September 2021
Putting Assessment, Care Plan and Transitions of Care Best Practices into Action. Presenter, L.A. Care Health Homes Webinar Series, Los Angeles, CA, December 2020.
Use of a Customized Electronic Transplant Patient Management System to Promote Regulatory Compliance. Primary author and Presenter, NATCO – The Organization for Transplant Professionals Annual Conference, Indianapolis, IN, August 2018.
Multidisciplinary Waitlist Management Efforts for Patients with Six or More Years of Qualifying Wait Time. Primary author on poster presentation, COIIN Learning Congress, Dallas, TX, August 2018.
Improved Accuracy of PSA Self-Reports Among Low-Income, Uninsured Men after a Public Health Nursing Intervention. Principal Author on poster presentation, American Public Health Association Annual Conference, Chicago, IL, November 2015.
Spirituality and Quality of Life in Low-Income Men with Metastatic Prostate Cancer. Presenter, American Public Health Association Annual Conference, Philadelphia, PA, November 2009.
Baskin A, Kwan L, Zavala MW, et al. The Impact of partnership status and social support on health related quality of life outcomes in men with prostate cancer. Urology Practice. 2017 May;4(3)225-31. full article
Zavala MW, Yule A, Kwan L, et al. Accuracy of PSA self-reports among low-income men with prostate cancer after a public health nursing intervention. Public Health Nurs. 2016 May 8. Doi: 10.1111/phn.12270 full article
Chamie K, Kwan L, Connor SE, Zavala MW, et al. The impact of social networks and partnership status on treatment choice in men with localized prostate cancer. BJUI 2011 Sep 2. Doi: 10.1111/j.1464-410X.2011.10515.x. full article
Zavala MW, Maliski SL, Kwan L, et al. Spirituality and Quality of Life in Low-Income Men with Metastatic Prostate Cancer. Psycho-Oncology. 2009 Jul;18(7):753-61. full article
Zavala MW, Maliski SL, Kwan L, et al. Longitudinal Quality of Life in Low-Income Men in a State-Funded Prostate Cancer Treatment Program. J Health Care Poor Underserved. 2008 Feb;19(1):200-14. full article