Population Health is Becoming Precision Community Health

Healthcare Rethink - Episode 76

This critical inquiry forms the backbone of the latest episode of Healthcare Rethink, A FinThrive Podcast. Host Brian Urban welcomes Jayme Ambrose, CEO of Adobe Population Health, to explore how her organization is leading the charge in this new era of healthcare. The discussion promises to unpack the transition from broad population health strategies to Precision Community Health, with community-focused interventions that address the social determinants impacting health outcomes.

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Brian Urban:

Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today we are talking all things population health. And who else could speak to this whole space better than CEO of Adobe Population Health, Jayme Ambrose. Jayme, thank you so much for joining our little show here today.

Jayme Ambrose:

Well, thank you Brian. I'm happy to be here. Thanks for inviting me.

Brian Urban:

This is going to be a lot of fun because we've gotten to know each other a little bit and you actually had an amazing saying when we first got to know each other, "You don't have to shovel sunshine." And I was thinking of that recently and talking about where we're at geographically.

And yourself, you're in Arizona. And this is kind of where we like to kick things off on the show, Jayme, love to have our audience get familiar with our guests and we want to start with who you are. And obviously you didn't start out with your doctor in nursing. You didn't start out as a CEO, but tell us who Jayme is. Take us back a bit.

Jayme Ambrose:

Well, the reason I can say you don't have to shovel sunshine is because I grew up in Indiana on a farm, so in rural Indiana, and so there was not, if we wanted to get down the driveway, which was about a quarter of a mile to get to the bus, then we were trekking through snow drifts in the winter and all of that. So that's been my life experience when it comes to snow. Not to say that it's not beautiful, but I would rather not have to trek through it or shovel it.

So Arizona's the best place to be in the winter. As far as my work experiences, I've been a registered nurse for over 30 years. I actually started out as a psychiatric nurse and I worked as a psychiatric nurse for 15 years and then moved into case management. And how that happened was I was working with a psychiatrist and he would say, and you may have to edit this Brian, but he would say, "We're all crazy, just some of us have jobs."

So when I transferred to work comp case management and had my first interview and they said, "Well, why would we hire someone who has psych experience?" And that was what I told them, was, "It aptly applies. Everything that I've done applies to being able to come work for you." And then that basically transitioned into a very strong community health focus in my nursing career, which ultimately then led to where I'm at now with Adobe.

Brian Urban:

I love it, Jayme. And there's so many nooks and crannies that you're leaving out that we're going to get into in a moment. And you've played so many roles. You have been a professor, a lecturer shaping young minds. You've been a healthcare practitioner on the front lines in psychiatric medicine as you'd mentioned, and then now you're a business founder.

I think Adobe Population Health actually came out of your doctorate work, in your dissertation, your research. And with all these different roles that you've played, what has been the most challenging thing to address at the individual level? And you can do this from the lens of, I guess in-home care management, but what's been the most challenging thing for you to address? Has it been social health needs, not having the right tools, the right data? What has it been for you?

Jayme Ambrose:

I think to me, the most challenging has really been what I'm doing now from in working. When we started Adobe, our first contract was rural Medicare population, so those that are over 65. And I wasn't really prepared for the level of poverty that we saw. I wasn't prepared to see individuals who didn't have functional bathrooms, that were unable to pay for their food if they paid for their meds. And so I think that has been probably the most difficult for me.

And the reason I say that too is because when you think of the senior population or I do, you equate that to your own grandparents, right? And so having to see those who were living with such loneliness, no family around, no neighbors around, that was really the hardest thing to really come to terms with because it was unexpected. And so what we've been able to do is really strongly address those issues and become that entity that solves those problems in the rural communities.

My grandparents, they lived on a farm up until they both passed. And yes, there was a lack of resources and as far as healthcare, right? We couldn't get them home health because there was nobody that came out that far, and so but the family was there to support them. They were never hungry. They never didn't have transportation to get where they went to. They were never cold or too hot because of lack of electricity or utilities. But there still was that gap in care that happens in rural communities. So I wasn't expecting it, I guess is really the truth of the matter.

Brian Urban:

And thank you for sharing those details in the family scenario and experience as well, because I think from a research perspective, a lot of us either in academia or in industry, see figures and facts and we don't see stories or the real experience of physically being with someone going through those challenges with... Makes it so much more real to us all.

And I am really thankful that you've seen this in different levels and you've seen it through Adobe. And I want to get to know Adobe a little bit more here because you're making some amazing impacts with people, meeting them where they are and understanding their needs and how you can help them improve their lives. So let's talk about Adobe Population Health, Jayme. Who's the organization today, tell us about the culture and give us the story here.

Jayme Ambrose:

So Adobe actually has a phenomenal story to share. As I said, we started out, now we're moving into our seventh year. We started out, we had 12 employees. We were in rural Arizona, and the message that came to us was very clearly with that contract was as a health plan, we're struggling. If you can make a difference, great. If not, this is a one-year contract for you.

So we were able to make a very positive financial impact for the health plan. We dropped their costs by 20% in one year, and at the same time, we were able to tell the story of how the health plan is supporting improving your quality of life. Right? So here we have nurses, social workers, nurse practitioners going into members' homes that, as we talked about before, had so many social gaps and we impacted that quality of life, which then decreased healthcare costs.

So here we are seven years later and we're in three states. We have over 350 employees, and we're still doing those very same things. And then you add into that, that we do all this data analysis. Right? We have the ability to take claims data and also data that we gather in relationship to social gaps and social needs and depression and loneliness, and put that all together to say, "Okay, this is a population we need to touch first because they're at highest risk and this is a population that has this significant need.

So we need to really focus on community resources in this area related to a higher percentage of poverty or homelessness." So that's really how it all comes together. So we say that we're a tech company because of all the data that we do and all the builds that we do, but we're different from most tech companies because then we put that human touch into it. Right? We're taking that data and then sending someone into the home to find out how do we solve this problem.

Brian Urban:

I think that is what separates you in a big way, is that you don't just have a sophisticated platform and data analysis that you share back to health plans on the lives you serve, but you're able to actually be with people and you have a very well-educated and socially aware team that actually goes into the homes of the lives that you serve as well.

So it's interesting looking at your story today, you've clearly gone past the traction gap. You have great impact for all the lives you serve and the customers you have in terms of health plans as well. But Jayme, I'm curious, I look at something on your site, it's clearly a flagship thing for you all. It's your Maslow survey.

And when I look at this, I say, "Okay, it's a survey based model. You're identifying needs and then you get insights and then you actually address them." But it's beyond that because a person is doing it not over telephone, not over paper or computer, but it's beyond that survey component. So take us beyond that survey component. What is this and what's the impact it's produced so far?

Jayme Ambrose:

So with our Maslow app, what it does is it asks 13 questions related to social gaps, right? So we're asking, "Do you have enough money for food? Are you safe in your home? Can you afford your utilities?" All of those kinds of questions that help us then hone in on what are the resources that this individual needs. And we place the QR code in physician's offices. It's also utilized by all of our team as they're going into homes.

When we do health fairs or we do popups at rural stores like the Dollar Generals, we're also utilizing it. So we're gathering that data. But what happens is, is that once that individual answers those questions, Maslow then geolocates for them the closest resource. So it's not zip code based. It's, "Here's the closest resource to you. Here's the distance from your house as to how far it will take," and then it sends them the map of where they to go.

The second thing that it does is it then notifies our social work team that someone has a need. So then our social work team is going to be reaching out to them to say, "Do you need help? Do we need to send a social worker to your home? Are you able to close this resource or help get this resource on your own or do you want us to continue to work with you?" So it just goes back to what we were talking about earlier, Brian, is that everything we do from a tech side, then we add that human touch component to it so that we're able to make that human connection and really address the issue.

Brian Urban:

And that's the thing that I find so fascinating is I think a lot of health plans, some I've worked for and some I've worked with for many, many years, have always tried to strike the right balance between enabling members through technology and then the human element of what healthcare has always been founded upon. So the social work team that you all have is very well-informed based off of Maslow here, this very sophisticated survey platform that you have an analysis that's provided, and then the individual is continued to be maintained in that loop it seems like.

So it's never a dusty data point or it may be captured a point in time, but it's always updated, which I find very fascinating because a lot of health plans today are deploying these surveys, they ingest them, and then they put them on a shelf, if you will, in a digital space. And then they're not really utilized downstream in a very helpful way to connect care. And I think that's what a lot of health plans are looking for help with today.

And you provide that obviously. So I think it's so fascinating that you're seeing technology is not everything, especially with rural based populations. But are you finding a level of certain sophistication with rural populations that are of general, I'd say generational poverty that are able to use technology very well? Or do they prefer having more of the human touch daily or I guess it just depends. I'm curious of what you're seeing in terms of a trend with the populations you serve of a rural setting and those that are maybe experiencing generational poverty.

Jayme Ambrose:

Well, I think there's a way to answer that, which I think you've probably heard many times. Before COVID, I would say that the use of technology and our ability to integrate with the population was more limited. Once COVID happened and we needed to reach them, it became, the use of telehealth became, it just boomed. And we've continued to utilize telehealth in many areas, especially for those who say, "Well, I don't want anybody to come into my home."

"Okay, well, are you willing for us to talk to you via a video chat of some type?" And they're like, "Yeah, I'll do that. I'm more than willing to do that." Or also what we also do is what we do is what's called a hybrid model where, "Well, will you let us bring this service to you, but then you can talk to our nurse practitioner via telehealth."

So then it's only one visit, right? Not two visits coming into the home. So we've been able to utilize that to help support even more patients than we did previously because everybody had to learn how to use it in order to stay in touch with their families. Right? They had to know how to FaceTime or whatever resource they were using to stay in touch with their family. So they became very, very comfortable with it.

Brian Urban:

I think that's really important to know is the pre and post aspects of going through a global epidemic, now an epidemic, a pandemic, and what's been challenging for a lot of companies to evolve into. But this is kind of now a standard cut into your offering, which is really nice to know. It's not just in the past, it's still gone with your model and how you serve. I'd say now, is it over 400,000 members that you have now? Which is an incredible figure and probably growing by the quarter.

So maybe I'm off a little bit here, but that's how many lives you have in your Adobe care management. But what's that really mean, Jayme? Is it continuing to get more and more people to serve and you're developing more features around your care management model, or is there some really cool statistics you can share around what you've been able to produce?

I mean, right sizing healthcare, obviously you're reducing spend, you're making things more efficient. Is there any engagement that you're seeing that's really improved that I think is probably getting more trust in health plans now with the members that are associated with them? I'm curious of anything that you can share in that space.

Jayme Ambrose:

I mean, there's many, many data points that I can share. And the 400,000 is a combination of Medicare, Medicaid and then some ACA marketplace population.

Brian Urban:

Wow. I didn't see that.

Jayme Ambrose:

And how we serve each of those populations is a little bit different. I'll give you some data in relationship to the Medicare first. In relationship to the Medicare population, if we are engaged with them in our case management process, we reduce their hospital readmission rate by 5%.

Brian Urban:

[inaudible 00:19:11]

Jayme Ambrose:

So we're able to, if we're engaged with them, we're able to then stop that readmission. We're also able to lower costs, overall healthcare costs by around 15% overall costs in relationship to that. And we're also then able to increase their utilization of their primary care visit, right? Because before we go in, they may have not seen their primary care in two years.

So we're able to then increase that primary care utilization at the same time, and also their medication adherence, meaning that they're now picking up their medications, taking their medications and really engaging with their PCP for their treatment plan. The other interesting statistics that I think is probably one of the most, to me, is the most interesting, one of the most interesting. Because you wouldn't think that it would be true.

So for those patients that we can't get ahold of, we have what we call a drive-by program. And what that is we route, we create routes, here's all the members that we can't get ahold of, and we send one of our care navigators out to knock on their doors, put a door hanger on their door, which says, "Call Adobe. We've been here," that kind of thing with that population, 80% of them, we are then able to reach out and make connections with within 30 days.

Brian Urban:

Wow.

Jayme Ambrose:

So-

Brian Urban:

You don't hear about that.

Jayme Ambrose:

I know.

Brian Urban:

No. No.

Jayme Ambrose:

And I literally made our data team redo the numbers twice because I didn't believe them. But the cool thing about that to me is that we're taking the technology, right? Here's all the data that says these are at need population. We're then taking and creating a routing system for them with the use of our software. And then again, adding that human touch to go out and gather, to gather more in so that we can continue to make those impacts.

Brian Urban:

I love the tactic used here because it's thoughtful, it's subtle, it doesn't show someone being invasive. You have a little door hanger notice and what better way to say, "Hey, we care. We stopped by."

Jayme Ambrose:

Right.

Brian Urban:

"We couldn't contact you." And then post 30 days, 80% of those attempts, you're able to engage and I would imagine maintain that engagement. That's priceless for a health plan, especially health plans, the ones that I know don't have great engagement or satisfaction scores as an industry to industry comparative. Health plans are among the bottom of the totem pole when you look across even utility companies having higher NPS scores.

So it's a great engagement mechanism that you offer too. I thought there was one to uncover here, Jayme and I didn't think that we would get to this type of story, but that's fascinating. And is this a newer engagement mechanism you've used or is this something that's been just working really well?

Jayme Ambrose:

No, we've always done it, but as our software has improved, it's become, to use your word, it's become more sophisticated. Right? Where we're able to do a better job of identifying the needed population and the routing of where we go. And so it has become more sophisticated, but we've always done it, just not as effectively as we've been doing it the past, I would say the past two years.

Brian Urban:

Wow. That's just fascinating. I think that's definitely the highlight of our conversation so far, and I'm just excited to see what more creative things will kind of spur off of ideas like that, those engagement mechanisms. So Jayme, I'm curious, you're obviously aware of the huge expansion of Medicare Advantage, SDOH supplemental benefit programs across the US.

Jayme Ambrose:

Right.

Brian Urban:

I feel like every conference we go to, there's [inaudible 00:23:50], there's a food tailored program, everything, paying your utility bills program, everything, which is great. A lot of players entering the space. I feel like your organization has always been a bedrock in that expansion as we're seeing players come in and out.

And are you seeing a lot of your growth because of the expanded benefits in terms of the customers you're serving, in terms of the amount of lives or I guess the amount of engagement that you're seeing? Has this expansion from 2019 really helped spur a lot of your growth so far?

Jayme Ambrose:

Yes, absolutely. I think the level of engagement and our ability to find where those needs are and address them. Because per the new SDOH CMS guidelines, that's the key, right? You've identified, now what are you doing about it?

Brian Urban:

Yes.

Jayme Ambrose:

So we are doing both of those things. One of the other things that Maslow does is it now auto codes all, every time we find a social gap, be it a food insecurity or any of the others, it now auto codes that Z code, which goes to the plan, which then goes to CMS.

So now they're getting that data, and then they also then have the ability to share, "And here's all of the touch points that have happened because of that," because we also then send the case management codes. Right? So we're able to now show, "Here was the food insecurity, here's what we did to address it," and we're able to close that loop for them.

And the other piece of it that plays into it is our ability to engage. Right? Because in the rural communities, the other pieces is that if Adobe has been into this neighbor's home and they say, "Well, how did you get that fixed?" Or, "How did that happen?" And they say, "Oh, well, Adobe helped me." So then when we call the neighbor and we say, "Hi, we're Adobe," and they say, "Oh, we know who you are. Yes, we want you to come and meet with us." Right? So it's that level of engagement, especially with the rural communities is another key to what helps us impact so many lives.

Brian Urban:

I think it is fascinating because so many people we talk to on our show address the idea of improving trust as a concept, but you've actually been able to do it as a measurable thing, and it's showing it because otherwise, these individuals that you're outreaching would not engage with you if they didn't have the foundation of trust to understand that you are safe to work with, that you're benefiting them and their families in some valuable way.

So I feel like you're definitely putting trust back in the pockets of health plans, back in maybe to the sense of humanity in healthcare and the ecosystem. So I am so excited for Adobe to just blow up and expand. This is so exciting. So I am curious too on the Z codes that you mentioned, a highly underutilized code that it's not a reimbursable code, but it's something that can help coordinate care downstream that directly affects healthcare spend.

And now it seems like we're finally coming to the dawn of realization that Z codes are a gold mine for data exchange and valuable information for care management and even going outside of the clinical world and the social health settings, research settings as well. So are you starting to see more utilization of Z codes with the health plans that are your customers now that you have a connection into them? Is it starting to be used more?

Jayme Ambrose:

Well, we built it, so we built the model to include the Z codes, and so every contract that we have, we utilize the Z codes within those contracts.

Brian Urban:

As a standard. Okay. Wow.

Jayme Ambrose:

A standard. Yeah. It has not been an ask so much as a give, right? We know that you are going to need this data soon, so let's get it ready for you so that you are already aware of what's happening. And what we're able to be able to see is that the Z codes are also showing us and to the plan, here's where your poverty levels are. Right?

Here's a county where we have 11% of the people that we have surveyed, 11% of them don't have enough money for food. So here's an area of concern that we all need to work together to, how do we address? Is it we need to absolutely support the community resources by doing a food drive for them to support the senior centers where they're feeding the elderly? All of these things. So once we have this data, then we work with the health plan to identify how do we work together to benefit that area.

Brian Urban:

That is fascinating, mainly because you're thinking the next several years ahead. There's a lot of great social healthcare tech organizations that we talk to on the show. We don't always get into the Z code space because of the obvious nature of it's not been utilized historically since its birth in the early 2000s. But it's great because CMS announcing not only the requirement of the social needs screening that NCQA has developed, but then addressing the identified needs and putting something into application.

So you're already thinking ahead, "Hey, you need to track this and have this documented and have this shareable within your organization and then outside your organization, we're going to give this." That is just, you're ahead of the game because I think a lot of places have thought, "Ah, I don't get reimbursed for it," or, "Ah, it's in the clinical notes. We'll use natural language processing and we'll pull it out."

Man, you're making it so much harder on yourself if you don't upfront use that. So that is something I did not know, researching organization or what we talked about before, Jayme, but that shows how thoughtful and strategic Adobe Population Health is. I love that.

Jayme Ambrose:

Aw, thank you, Brian. Thanks.

Brian Urban:

Yeah, that is just one of many things that I think you bring to the table. So with all this great stuff said and everything that we've talked about so far, Jayme, I want to take a look into the future here. Five plus years down the road, what does Adobe Population Health turn into? What will be your greatest contribution to the lives you serve or maybe the ecosystem at broad be?

Jayme Ambrose:

I think our path has always been that we change how healthcare is delivered, right? I think we've proven year after year with the outcomes that we provide, that it's not about another pill, it's not about another specialist to see that is going to make that significant impact. It's about how do we improve the quality of life?

How do we ensure that health equity? Because if I don't have enough money for food, I don't really care what my blood pressure is, I'm not going to be focused on that. If I'm not in a safe environment, I'm not worried about taking my diabetes medicine. So it's really about how do we ensure that quality of life and the equity of it, and that's what we do. The issue that comes up with all of that, especially with the elderly population, is that they're not out there telling people, "I have these problems."

Brian Urban:

Right.

Jayme Ambrose:

Physicians aren't asking, their providers aren't asking them in this moment if they have enough money for food because they don't know what to do if they say yes. So if we're able to add this piece of caring for quality of life to improve health, if we're really able to incorporate that, that's what Adobe's focus is on how we do that.

Brian Urban:

Wow. I think just simply for my observation today, you're there, but now when you get to a scaled place, you're serving so many more lives, your impact is going to be undeniable. I'm so excited that there's a person out there, a leader out there like yourself, Jayme, that understands the struggle of the individuals that your technology and your social health worker team is serving. And I am just so thankful that you're able to join our little show here today.

Jayme Ambrose:

Well, thank you very much. I've enjoyed it. I've enjoyed our conversation. All your questions were very thought-provoking, so I appreciate that.

Brian Urban:

This has been fun. Thank you, Jayme. And for more exciting excerpts and insights, please visit us at finthrive.com.

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