By Jayme Ambrose

It all started as a project for a class I was taking for my doctorate. After developing the idea for a new model of health care that would better address gaps and disparities impacting health, a nudge from my professor inspired me to take my thesis from concept to reality. Shortly after completing my doctorate, I pursued an opportunity to pilot the program and began building on the original model. In 2018, opportunity knocked again, and I officially launched Adobe Care & Wellness.

My goal was and is to improve health care and help create better outcomes. I have witnessed firsthand that using technology to help track and analyze risk and combining that information with the delivery of more proactive and personalized care is proving effective. The combination of data and human touch is a holistic model that improves quality of life and health.

Technology is a powerful tool, but technology is not capable of fully recognizing things that can only be seen by the human eye. As a 30-year veteran in nursing with an extensive background in case management I’ve seen it all. I’ve seen patients having difficulties recovering from a medical procedure or suffering from health issues to discover it was because they did not eat regularly or take their medications properly. When you begin to investigate the situation, you may discover they don’t have access to food, the money to pay for medications and/or maybe they don’t have a way to physically get where they need to go.

To begin making a change, we need to uncover and address the many disparities. We need to engage with patients to know and understand what they need to be well. This is especially true for seniors. Many are living alone or with another aging family member., They are on a fixed income and do not always have access to what they need, which takes a toll on their health.

Identify issues, reduce risks

Loneliness and poverty are two of the biggest concerns in our aging population. The elderly is often left behind due to environmental and family circumstances. One of the first steps to change or overcome these challenges is to assess and identify the risk level of a patient or individual. Our IT team developed a risk stratification tool to identify concerns and issues that can or will impact an individual’s health.

The ongoing advancement of technology and how its integrated into health care will bring the biggest changes to the industry in the next 10 years. Technology such as AI, robotics and telehealth will continue to change how we monitor and treat patients and how we are can deliver care.

Why we need to take a holistic approach to tackle disparities

When a health care provider treats a patient, they traditionally look at the specific symptoms or ailment and provide specific treatment. What we know from experience is it is essential to look at the whole person to truly improve health. That means both mental and social factors, not just considering the symptoms of an immediate or ongoing ailment. If we fail to see the person as a whole and only their symptoms, we are failing them as health care providers. In addition, the impact on health and quality of life also has a financial impact. If we can reduce or eliminate the factors or disparities contributing to poor health, we can also reduce health care costs.

Steps to better health

We know that when you utilize technology with personal interaction the outcomes will improve. Here are a variety of steps or tools we can incorporate to better meet the needs of patients diagnosed with a chronic illness or faced with a release from a hospital stay:

  • Telemonitoring and tracking: Monitoring a patient’s status or progress via technology is an effective line of defense for proactive care.
  • Home visits: Meeting with a patient at home allows a health care professional to learn if the home is set-up to ensure a patient has what’s needed to support a positive recovery; cleared areas for walking, rails in bathrooms, working heat or air conditioning, food in the refrigerator. These are all factors that can impact health and cannot be seen during an office visit.
  • Nutrition: Diet is key in preventative care and healing. It is essential for those at risk for diseases such as diabetes, heart, and kidney disease. Incorporating counseling with a dietician or nutritionist is invaluable to improving health.
  • Daily therapies: Physical therapy and/or counseling can be delivered at home or in office. We need to always consider mobility and mental health to provide a pass to wellness.

Access to information allows us to better serve patients. It also allows us to track data related to patient health and treatment, and measure results. Stats we monitor include reductions in hospital readmits, insurance claims, pharmacy refills and decreases in ER visits. These are indicators that our holistic approach is working.

Recognition and rewards

In August, I was recognized by the Phoenix Business Journal with a Health Care Heroes award in the “Innovator” category. While I’m humbled to be honored, the real honor is improving the lives of the people we care for., It’s a privilege to work with my team as we develop new tools that make it possible to address these disparities, and to work with the health care partners and insurance providers that are supporting our roll out of a holistic approach to deliver care. Through our proprietary technology, coupled with a human touch, Adobe Care & Wellness is helping to close these gaps for more than 40,000 lives.

Interested in learning more about AI and the future of case management? Visit the CMSA ERL for courses on technology from our recent 2021 Conference!