Dr. Jeffrey Brenner and Camden Coalition Staff

Creating partnerships in California

Camden Coalition and Adventist staff in Ukiah Valley, CA

The technical assistance work of the Camden Coalition and our National Center for Complex Health and Social Needs has taken us all around the country. We have helped a diverse set of partners: large health systems, local nonprofits, public health departments, and more, deliver better care to their most expensive and complex patients. For us, the most exciting moments are when we are able to forge partnerships between different institutions that are caring for the same patients, just like we do in Camden every day.

One of those moments happened recently in California’s rural Ukiah Valley, where Adventist Health and Mendocino Community Health Center came together to case conference about their most complex shared patients.

Adventist Health is a large nonprofit, faith-based health care system on the west coast, with over 20 hospitals and medical centers across California, Oregon, Washington State, and Hawaii. Like many large health systems across the country, Adventist wanted to figure out how to better identify and care for their patients with complex health and social needs. When these patients don’t get the care they need, they can end up trapped in cycles of health crises, emergency room trips, and hospitalizations that are harmful to the patient and expensive for the system.

We started working with Adventist in 2016, helping them form interdisciplinary hotspotting teams in five of the regions they cover, improve their data infrastructure, and form an integrated model for complex health. In Ukiah Valley, where the burden of poverty and addiction is high, Adventist’s street medicine program and deep community partnerships have helped ground their hotspotting work.

One of their community partners in Ukiah is Mendocino Community Health Center (MCHC), a Federally Qualified Health Center (FQHC) that we happen to be working with on a different project: a grant funded by the California Health Care Foundation to partner providers and payers to develop and implement complex care interventions for patients with high ED and/or high opioid use.

When we learned that one of the highest utilizing patients in the area had been identified by both MCHC and Adventist, we facilitated a case conference at one of MCHC’s clinics to dive deeper into the patient’s needs and how the two organizations can collaborate on shared solutions.

“Solving complex situations is tough to do in one organization,” said Lauran Hardin, Senior Director of Cross-Continuum Education at the Coalition and National Center faculty member. “Case conferencing across agencies not only improves outcomes for individual patients, but can also accelerate process improvements between organizations. It really broadens the team working on important solutions for vulnerable people.”

Just like in Camden, where bringing together rival hospitals to form the membership of the Coalition paved the way for initiatives like our Health Information Exchange and the South Jersey Behavioral Health Innovation Collaborative, we hope that the case conference between Adventist and MCHC will spark new avenues for collaboration.

For now, Adventist and MCHC will be meeting every two weeks to develop a shared framework to care for patients with complex health and social needs.

“[MCHC and Adventist] are collectively the community’s safety net, and we have a unique opportunity, and in fact responsibility, to create a highly collaborative, shared system of care,” said Sam Fernandez, Director of Behavioral Health at MCHC. “This is essential to improve the outcomes of our most complex patients and the community at large.”

Interested in learning more about technical assistance from the Camden Coalition? Email [email protected].

Posted: June 14, 2017