Moving forward by stepping back: A complex care case study from Adventist Health Hanford

Care management & redesign

Loretta was in a tough spot. She had violated curfew at the inpatient rehab center where she had been court-ordered to enroll, and as a result had been kicked out of the program and sent to a homeless shelter in another town in California’s Central Valley. It looked like, despite the progress she had made toward addressing her substance use disorder, she might be back to the same cycle of jail and emergency room visits that had landed her on the radar of the new Community Care Visit program at Adventist Health Hanford in September 2017.

This time, though, she had an Adventist care team around her, trained by experts from the National Center for Complex Health and Social Needs in complex care techniques like interprofessional teaming, building authentic healing relationships, and care planning based on patient goals. Davinna Cavasos and Elvia Hamner, care coordinators Adventist Health Hanford, were there to catch Loretta when she stumbled. They advocated for her in the courtroom; secured her a spot at Casa del Rio, a long-term care facility where she would receive both housing and care; and connected her with community mental health resources.

The power of relationships

The key to the Adventist Health Hanford team’s work is in building authentic healing relationships with their patients, with each other, and with their community partners. “It’s about a relationship of individual respect,” said Elvia: “seeing the other person as a caring, kind human. A lot of times people lose that— they see other people for what they’re doing, not necessarily who they are.”

“This work takes a lot out of you,” said Martha Heavrin, clinical manager at Adventist Health Hanford. “You have to thoughtfully assemble the right team to support the patients and to support each other.”

Having the right team can lead to dramatic results for both the patient and their providers. Dr. John Zweifler, Regional Medical Director at Adventist Health Hanford, says that the last time he saw Loretta, who has diabetes as well as a substance use disorder, “her sugar was way out of control. But since she had a caseworker with her, I felt like I had support, and could strategize with the team. If I saw her in a vacuum, it would be much more frustrating, rather than the satisfying experience that it’s been.”

Loretta has not been back to the emergency room or admitted to the hospital since she started working with the team in September. Instead, as her utilization chart below shows, she has been accessing regular (and much less expensive) outpatient services. And most importantly, she has made huge progress toward her goal of getting to see her children again: she is now having supervised visits with her youngest child.

A chart showing Loretta's healthcare utilization: x axis shows dates when she used healthcare services, and y axis shows cost of each encounter. The chart shows many tall bars representing ED and inpatient encounters until September 2017, and only very short bars representing outpatient encounters after September 2017.

Loretta’s care team members aren’t the only ones noticing the change. “The third time we accompanied her to court,” Davinna said, “the judge said, ‘I can tell that you’re changing, that you’re doing something better for yourself. Keep it up.’ To see him, a judge, notice that difference in her was a winning moment.”

Getting the right tools

in 2016, Adventist Health West, which includes 22 hospitals across California and Portland, began a training relationship with the National Center. The Hanford team launched their complex care model last year; before last June, Davinna and Elvia were working as schedulers at the hospital, not community care coordinators.

Along with four other Adventist sites, the Hanford team worked with National Center faculty like Victoria Sale, senior director of integrated community care, and Lauran Hardin, senior director of cross-continuum transformation. Pulling from their experience building complex care programs at the Camden Coalition and Trinity Health in Michigan, Victoria and Lauran taught the Hanford team techniques like creating a backwards plan with patients using the Camden Coalition’s COACH model.

With the backwards planning tool, patients place cards that correspond with their needs and goals on a sheet divided into quadrants that let providers know whether they need to work on the issue or not, and whether they want to work on it right now or later.

“The quadrants help us to identify patients’ needs and to better prioritize,” said Davinna. “It helps us visualize where the problems are.”

Adventist Health Hanford had recently taken on risk with a large Medicaid population, said Lauran, and wanted strategies to stabilize a population facing a lot of structural barriers to good health. The techniques they learned from the National Center will make sure they can care for this population’s complex needs without getting overwhelmed.

“They were the light at the end of the tunnel,” said Elvia. “As a team you have to go in knowing that you can back each other up. The National Center team helped by teaching us to give ourselves the time to get to know our patients. They said it was ok to take a few steps back.”

Learn more about training relationships with the National Center