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Integrating Technology and a Human Touch in Population Health

Apr 22, 2024

Social determinants of health (SDOH) play a significant role in health disparities and inequities in the U.S., leading to poorer outcomes and increased mortality. In fact, up to 80% of health outcomes are driven by SDOH, and its impact is evident: 10.2% of U.S. households experience food insecurity at some point annually, 5.1 million households have very low food security, 37.9 million people live in poverty, and one-third of Americans are unsure about accessing medical care when needed.

While federal programs address some aspects of SDOH, other care management organizations struggle. The siloed nature of resources, lack of technology-based interoperability, and misaligned financial incentives hinder comprehensive approaches. As a result, SDOH factors often go unnoticed by providers and health plans due to limited data utilization and the challenges of coordinating support across geographic areas.

Building a more effective care model for the future

In 2016, I contracted with an insurance company to launch a wholistic case management initiative for Medicare members, launching the Adobe Care Management (ACM) model. The ACM model offers a wholistic approach led by nurses, driven by technology, and focused on the individual including services such as Proprietary Risk Stratification, Health Risk A

ssessments, Care Gap Resolution, SDOH Intervention Support, and Transitional Care Management.

To build a more effective care model for the future, it is essential to overcome the limitations faced by health plans and providers in addressing SDOH. Many lack access to the necessary data to create a wholistic view of patients and members, and practices struggle financially to incorporate social needs into treatment. Without a comprehensive understanding of SDOH factors, health plans are ill-equipped to manage risk, costs, and the health of the populations they serve.

The ACM model leverages both technology and a human touch to create an integrated, wholistic program that prioritizes the individual. Patients and members benefit from improved health and quality of life, while providers see increased STARS ratings and improved value-based reimbursement. Health plans gain access to more comprehensive data, leading to improved Medical Loss Ratio (MLR) scores, healthier members, reduced costs, and more effective risk stratification. Communities benefit from healthier citizens, lower costs, and better utilization of available social services.

Proprietary risk stratification and health risk assessments

The ACM model employs a proprietary risk stratification tool that reviews algorithm-driven data to identify individuals at the greatest risk of hospitalization. These high-risk individuals are contacted within 30 days, resulting in a 10% decrease in hospitalization rates. The initial step involves a short survey conducted by the care team in the patients’ homes to identify SDOH barriers and gaps in care – crucial, as 80% of hospitalizations are related to SDOH.

The MASLOW™ app gathers gap data and presents an individual’s needs as a pyramid, with SDOH factors forming the foundation. MASLOW™ automatically identifies local social support resources for food, shelter, transportation, mental health, and other services. This information is then shared with the patient through text or email, and an Adobe social worker is notified and schedules a contact. MASLOW™ facilitates connections between members and personalized resources, while the Adobe EMR retains this information and generates reports, conducts analyses, measures results, and proactively removes barriers to care.

Care gap resolution and SDOH support

The ACM model emphasizes a team approach. Nurses, nurse practitioners, social workers, support coordinators, dieticians, care navigators, and transition specialists leverage technology to deliver personalized care. The team conducts home safety assessments of those identified as high-risk to identify gaps or disparities, then works together to proactively monitor and address these challenges in the patient’s living environment.

The personalized preventative care plan is based on individual needs and includes telehealth, in-person screenings, check-ups, and comprehensive wellness assessments. Information is tracked to validate positive changes, enhance health literacy, and support the management of chronic and acute conditions.

One in five patients experience an adverse event within three weeks of discharge, but the Adobe interdisciplinary team’s continuous monitoring, assessment, and communication play a critical role in improving adherence, reducing complications, and preventing re-hospitalizations.

Innovative technology

The model relies on innovative technology to overcome existing limitations. Adobe developed a proprietary Electronic Medical Record (EMR) system, as existing EMRs were incompatible with this comprehensive approach to care management. Salesforce and MuleSoft product suites were utilized to facilitate data communication between Adobe and health plan partners. Real-time reporting, includingSDOH factors captured

through risk stratification tools and the MASLOW™ database, became more accurate through the bi-directional bridge, saving time and resources by eliminating manual record entry.

Outcomes

The value-based care model places financial risk on outcomes, and the ACM model’s hyper-individualized care experiences lead to improved access, outcomes, and quality of life. By enhancing health management, health literacy, and care coordination, the model reduces complications and costs while encouraging reinvestment in front-end SDOH services such as food pharmacies and transportation.

Currently, more than 400,000 people participate in the ACM model, which has resulted in significant improvements. Over a two-year period, there has been a 75% decrease in ER claims, a 33% reduction in claim costs (year-to-year data comparison), a 23% decrease in pharmacy claims (quarterly data comparison), and a 9% reduction in hospital readmission rates.

Dr. Alina Walden – Vice President Clinical Services

Dr. Alina Walden is a highly accomplished professional with an impressive academic background. She holds a Bachelor of Science degree in Biochemistry and Molecular Cellular Biology from the University of Arizona Honors Program. Subsequently, she obtained her medical degree from New York Medical College and earned her MBA from the University of Phoenix.

With over 15 years of experience in clinical practice, Dr. Walden has specialized in risk adjustment, disease management, and utilization management. Her expertise as a physician executive, combined with an in-depth understanding of the CMS HCC-Risk Adjustment Model and Quality STAR measures, enables her to develop and implement effective population health programs. She is also certified as a Certified Professional Medical Auditor (CPMA), Certified Professional Compliance Officer (CPCO), Certified Professional Coder (CPC), and Certified Risk Adjustment Coder (CRC) from AAPC. These credentials align perfectly with the goals of Adobe Population Health.

Dr. Walden is committed to delivering exceptional customer service to the entire care team, consistently striving to enhance and promote positive patient experiences. She firmly believes that every individual involved in the healthcare process plays a crucial role in advocating best practices. Outside of her professional endeavors, Dr. Walden cherishes spending quality time with her family, which includes her loving husband and four children. Her personal interests include reading and traveling.

Gail Lara – Vice President Strategic Outreach

With extensive experience in healthcare marketing, operations and management, Gail has made a career of developing and growing service lines and businesses from large health systems and specialty practices to wellness and ambulatory services.

As a VP at Adobe Care & Wellness, she oversees outreach to physicians and identifies opportunities for growth that align with the needs of the community and its members.
Gail earned an associate degree in business at Midland College followed by a bachelor’s degree in marketing from the University of Texas. She then worked in operations and business development with a national company upon moving to Arizona and joining the state’s largest urgent care organization where she was instrumental in its growth, identifying new locations, opening clinics, and overseeing licensing, staffing, and compliance. Gail then built and grew service lines at a local hospital group and oversaw marketing and business development for another.

With a commitment to innovative thinking, Gail’s wide range of experience is enhanced by her ability to foster collaborative relationships to achieve goals.

Residents of Arizona, Gail, and her husband have three children. She is passionate about community service, has served on the board of the Arthritis Foundation, and regularly volunteers at The Society of St. Vincent de Paul.

Maria Martinez – Vice President Population Health

Maria Martinez started with Adobe Care & Wellness in the call center, making health risk assessment (HRA) calls to members. She soon took on new responsibilities, learning the ins and outs of Salesforce and helping to build the company’s initial technology platform. Maria never expected that her first post-college job would lead to a career in health care solutions. Maria was born and raised in Phoenix and earned a Bachelor of Science in justice studies with a minor in women and gender studies, graduating Summa Cum Laude. She quickly rose to Senior Director of Clinical Services at Adobe Care & Wellness and later to Vice President of Operations. As VP of Operations, Maria oversees the nurse practitioner scheduling and in-home assessments program to ensure members receive the care needed. She is passionate about making health care more accessible to those living in rural areas or lacking the mobility to get to a doctor’s office helping the company grow and expand its ability to help others.

David Heinrich – Vice President, Integrated Care

A Chicago native with more than 20 years of management experience, David began his management career in the retail industry, quickly working his way up to Store Manager and then Regional Manager. While overseeing multi-million dollar retail stores, David felt the pull to venture into the medical field. He began working for an ambulance company providing pre-hospital care to the sick and injured which inspired him to further his education in nursing school. As he earned his degree, David worked full-time doing organ and tissue recovery for one of the nation’s largest not-for-profit body donation programs.

Since graduating as a registered nurse, David has worked in medical-surgical, trauma, and telemetry units as well as in home health, hospice, and nursing education. He has held clinical leadership roles including Clinical Manager and Director of Nursing.

When Adobe Care and Wellness started their Special Needs Plan in 2019, David joined the team and quickly helped grow the program. He was promoted to Director of Case Management and then to Senior Director of Integrated Care. David, who is also a Certified Case Manager, now serves as Adobe’s Vice President of Integrated Clinical Services.

Alex Waddell – Chief Information Officer

Alex Waddell is an Arizona native and graduate of Arizona State University, where he earned a Bachelor’s in economics. Alex began his career in IT as a software developer for a home health and case management provider. Over the next four years, Alex took on increasing responsibilities and began earning certifications as a Salesforce developer. In 2018, he was hired as Director of Software Development for Outreach Health Services, where he worked for two years before accepting the position of Executive Vice President of Technology at Adobe Care and Wellness. Alex has continued his drive for excellence and is now a Certified Salesforce Application Architect as well as a member of the Forbes Technology Council. In his current position as CIO,  Alex manages and directs a team of developers and oversees the design and development of the proprietary software that supports the expanding healthcare solutions Adobe Care and Wellness offers. Alex and his department, provide internal staff and external entities with analytics that measures results and helps drives decisions. He and his team also ensure data security for the company’s hardware and software.

Chad Wolver – Chief Financial Officer

36-year-old Arizona native Chad Wolver brings nearly a decade of commercial banking, strategic finance, and management experience to the Adobe Population Health leadership team. Phoenix-based Adobe Population Health ranks 2,271 on the 2023 Inc. 5000 annual list of the fastest-growing private companies in America.

A graduate of the University of Arizona’s Eller College of Management, Chad earned an Executive MBA with a focus in Accounting and Finance. While serving as Vice President at Bank of America, Chad was the banker for Adobe Care & Wellness (rebranded as Adobe Population Health in 2022), which has experienced 242% three-year growth from 2020 to 2023.

CFO since 2021, Chad has managed Adobe Population Health’s strategic financial strategy, overseeing its budget by using technology to create efficiency, synergy, scalability, and deeper insight to grow the organization efficiently as it expands as a multi-state provider.

Chad serves on the boards of some of Arizona’s most well-recognized philanthropic organizations, including Arizona Community Foundation’s Kellenberger + Tollefson Center for LGBTQ Philanthropy Advisory Council and ONE Community’s Millennial Advisory Board. He’s a past board member of ASU Lodestar Center’s Leadership Council, Human Rights Campaign Arizona, Southwest Center for HIV/AIDS and Phoenix Community Alliance’s Social & Housing Advancement Committee.

In his free time, Chad enjoys traveling with his partner and spending time with their beloved Italian greyhounds.

Challas Ray – Chief Operating Officer

Challas Ray has spent more than a decade building a career in the health care industry. Challas holds a Master’s in Clinical Kinesiology from Eastern Illinois University. After completing his education, he began work with Sara Bush Lincoln Health System, where he helped create and expand an external wellness program for companies interested in providing wellness programs to their employees. Challas is originally from Toledo, Illinois, but now calls Arizona home.  He moved to the Valley of the Sun seeking warmer weather and new opportunities. Joining The Beech Group as a Transitional Specialist, it was there Challas met and began collaborating with Jayme Ambrose. In 2017, he joined Jayme’s team to help launch Adobe Care & Wellness. As Adobe Care & Wellness COO, Challas provides oversight of the operational process to improve efficiencies and conducts the cost-benefit analysis of new and existing initiatives.

Pat Duryea, PhD – Chief Inspiration Officer

Patricia (Pat) Duryea earned her bachelor’s in Business Administration with an emphasis in Human Resource Management from Arizona State University. She then served as a Human Resource Director for nearly six years before returning to school to earn a Master of Educational Psychology from Northern Arizona University and a Doctorate in Counseling Psychology from Walden University.  Through her career spanning three decades, Pat has worked as a clinical manager, employee assistance program director, an adjunct professor at ASU and she’s owned and operated multiple small businesses. She has extensive knowledge in developing health and wellness programs, and experience in trauma-related counseling. As Chief Inspiration Officer at Adobe Care & Wellness, Pat manages human resources and the development of company culture.  She also serves as the compliance officer, receiving complaints, solving issues and reporting them to Arizona Complete Health.  She works directly with the management team on leadership development within the organization and monitoring morale. Pat’s overall focus is to ensure that employees feel included and valued in their contributions to the company’s success and to provide them with the opportunity to be the best they can be.

Jayme Ambrose DNP RN CCM – Chief Executive Officer

Jayme Ambrose, DNP, RN, CCM, is the visionary Founder and Chief Executive Officer of Adobe Population Health, an Arizona-based company offering an innovative, first-of-its-kind solution to the issue of health equity. Founded in 2018, Adobe employs a technology-driven model for interventional care management and takes a holistic approach to population health by closing care gaps, reducing costs, and caring for the whole person.

Armed with a Master of Science-Nursing from Arizona State University, Jayme was accepted into the Doctoral program for Nursing Science & Leadership at Case Western University. It was there, she developed an integrated case management model, as part of her doctoral thesis, with the objective of addressing the social determinants of health that often contribute to poor health outcomes for at-risk populations. After completing her doctorate in 2012, Beech Medical Group agreed to pilot her model, if Jayme agreed to accept a position as VP of Clinical Services. In 2016, she signed her first insurance company contract and initiated a holistic approach to case management for Medicare members. Her model integrates data analysis and risk assessment with a human touch to deliver proactive and preventative care that improves health outcomes, decreases hospital and ER visits, and reduces overall healthcare costs. In 2018, Beech Medical Group sold the company but not before giving Jayme the opportunity to purchase her division. On that day, Adobe was born with one mission: To positively impact the lives we touch.

As part of an innovative technology platform, Adobe utilizes proprietary risk stratification tools to identify the issues of those at greatest risk including food insecurities, financial hardships, transportation issues and even loneliness. And then through a proprietary and ground-breaking application called MASLOW™, members are invited to answer questions related to social determinants of health and then are connected to for-profit, non-profit, and governmental resources based on geolocation. To ensure impact, a qualified team member through a hybrid care model reaches out to offer assistance, closing the care loop. It is this human touch that sets Adobe apart from other case management organizations. Today, Adobe employs 300 nurses, nurse practitioners, social workers, support coordinators, dieticians, care navigators, and transition specialists and serves more than 200,000 elderly and underserved patients across three states.

Jayme has served on several boards including The Arizona Homecare Association, The American Association of Occupational Health Nurses and the Case Management Society of America where she is currently a member. She also currently serves on the PAC board of the Arizona Nurses Association. In addition, Jayme is currently adjunct professor for Arizona State University where she teaches RN to BSN and MSN students and develops curriculum.