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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.

Patrick Randall, SVP, Business Development

Patrick Randall is a dynamic senior leader with more than 30 years of diversified healthcare experience and a powerful blend of national sales leadership, client relationship management, and operational expertise. He has a strong track record of negotiating complex, high-value deals and driving strategic growth across the payer, provider, and senior care markets.

As SVP, Business Development at Adobe Population Health, Patrick leads business development strategy and expansion, helping to deliver innovative solutions that improve care outcomes for vulnerable populations. 

Throughout his career, Patrick has held executive roles at leading healthcare organizations including Tegria, Vital Data Technology, and Independent Living Systems. He is known for building high-performing teams, cultivating trusted client partnerships, and delivering consistent results—such as securing multi-million-dollar contracts and building robust sales pipelines.

Patrick resides in the Twin Cities metropolitan area of Minnesota, where he maintains an active role in the community and serves on the boards of two local charitable organizations. He holds a Bachelor of Arts in Business Administration from the University of St. Thomas in St. Paul, Minnesota. In his personal time, Patrick enjoys being with his family and spending time outdoors at his lake residence in Northern Wisconsin.

Matthew Guanzon – Senior Vice President, Payor Strategy & Growth

Matt is a seasoned healthcare executive with over 15 years of experience in managed care, payor & provider strategy, contract negotiations, and value-based care. He has held leadership roles in national provider and payor organizations including Humana, Optum, and UnitedHealthcare, leading provider contracting, network expansion, and risk-based payment initiatives. As Senior Vice President of Payor Strategy & Growth at Adobe Population Health, he leads payor partnerships, business development, and strategic initiatives to drive innovation in healthcare delivery.

Matthew holds a Master of Health Administration from Indiana University and is passionate about healthcare transformation. Outside of work, he enjoys pickleball, golf, tennis, cycling, and volleyball.

Caroline Khan, MHA – Market President

Caroline Khan is a results-driven healthcare executive with extensive experience leading health plans and medical group operations.  With a strong background in value-based care, risk adjustment, compliance, and patient-centered program development, she has held leadership roles in major organizations such as WellBe Senior Medical, Molina Health Plan, Cigna and HealthCare Partners Medical Group.  Caroline has a proven track record of optimizing healthcare delivery, developing innovative home-based and paramedic models, and driving strategic growth.  Her expertise in operational excellence, provider integration and regulatory compliance has led to significant improvements in patient outcomes and financial performance.

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 19 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 & Communications

With extensive experience in healthcare marketing, operations, and management, Gail has built a career around developing and expanding service lines and businesses across large health systems, specialty practices, wellness, and ambulatory services.

As Vice President at Adobe Population Health, she leads strategic outreach to physicians and providers, identifying growth opportunities that align with community needs. Her role also includes oversight of marketing and promotional initiatives, ensuring cohesive messaging and increased visibility for Adobe’s programs and services. Gail plays a key role in strengthening provider relationships, enhancing engagement, and driving initiatives that support improved health outcomes and population health strategies.
She earned an associate degree in business from Midland College, followed by a bachelor’s degree in marketing from the University of Texas. After relocating to Arizona, Gail worked in operations and business development with a national healthcare company, then joined the state’s largest urgent care organization where she helped drive expansion—identifying new clinic sites, overseeing licensing, staffing, and compliance. She later built and managed service lines at a local hospital group and led marketing and business development efforts for another healthcare organization.

Known for her innovative thinking and collaborative approach, Gail’s wide-ranging experience allows her to build strong partnerships and deliver results across a variety of healthcare settings.

A longtime Arizona resident, 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 – VP Operations

Maria Martinez is the Vice President of Operations at Adobe Population Health, where she has had the unique privilege of growing alongside the company since its inception. Being part of Adobe from the ground up has given her a deep-rooted connection to its mission and a clear vision for how the organization can continue to evolve and expand its impact.

Maria graduated summa cum laude from Arizona State University, where she built a strong foundation in leadership, strategy, and systems thinking—skills that have proven essential in navigating the ever-changing healthcare landscape. In her role at Adobe, she leads the company’s national risk adjustment and quality programs, ensuring the delivery of efficient, compliant, and member-focused solutions across all the states Adobe serves.

Maria is passionate about increasing access to healthcare for underserved populations, particularly those in rural communities or individuals who face barriers to visiting a doctor’s office. This commitment drives her work and fuels her dedication to innovation and operational excellence.

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 Population Health. 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 Population Health offers. Alex and his department provide internal staff and external entities with analytics that measure results and help drive decisions. He and his team also ensure data security for the company’s hardware and software.

Chad Wolver – Chief Financial Officer

37-year-old Arizona native Chad Wolver brings over a decade of finance and management experience to the Adobe Population Health leadership team. Phoenix-based Adobe Population Health ranks 1,749 on the 2024 Inc. 5000 annual list of the fastest-growing private companies in America and was recently recognized by the Phoenix Business Journal as the 13th fastest growing privately held company in Arizona in 2024.

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 543% growth from 2020 to 2024.

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 has expanded to serving over 500,000 Medicare and Medicaid lives in 8 states.

Chad has served 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 Community’s Multicultural Advisory Board, 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, Marco, 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 healthcare 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 Population Health. As Adobe Population Health 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 that she developed an integrated case management model as part of her doctoral studies, 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 2013, Beech Medical Group agreed to support piloting 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 groundbreaking application called MASLOW™, members are invited to answer questions related to social determinants of health and are 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 over 300 employees in clinical healthcare services, data analysis, software development, and administrative roles, serving more than 400,000 across the lifespan and in eight states.

Jayme is a member of the Arizona Nursing Association and 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 of the Rural Special Interest Group Advisory Panel. Jayme also serves on the Women’s Executive Leadership Team of the American Heart Association.