Transforming Care: Reporting on Health System Improvement

Transforming Care, The Commonwealth Fund’s newest publication, focuses on new models of care, payment approaches, and patient engagement strategies that have the potential to reshape our delivery system to better meet the needs of the nation’s sickest and most vulnerable patients. Published quarterly, the newsletter is a source of innovative ideas for health system leaders, clinicians, and policymakers.

  • June 29, 2016 Issue
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Profile: Emily Adler, Health Resilience Specialist for CareOregon

As one of 32 health resilience specialists employed by CareOregon, the state’s largest Medicaid managed care plan, Emily Adler works with high utilizers who’ve frequently been hospitalized or visited the emergency department for what appear to be avoidable problems. More than half of these patients have experienced trauma, which often manifests in the difficulties they have managing their health. Because Adler, a social worker, finds such trauma affects her patients’ willingness to seek care, she keeps this in mind as she offers them help navigating the care system, connecting to social support services, and achieving their health goals. An evaluation of the program found that on average, behavioral health visits among members working with health resilience specialists increased by 16 percent, while E.D. visits and hospitalizations dropped by roughly 20 percent.1  



When I describe our work, I talk about how we’re identifying people who are not getting their needs met for whatever reason—what we do at a basic level is to try and meet them where they’re at and figure out what’s happening.

Emily Adler and Patient Angela

Emily Adler, M.S.W., a health resilience specialist with CareOregon, helps patients navigate the health care system. More than half of the patients she serves have experienced trauma.


Because we are assigned to primary care practices but are employed by the health plan, we know what their diagnoses are and how they use services; what we’re trying to do is take a step back and look at the bigger picture.

We don’t screen for trauma. When you find out someone has been homeless for 10 years, has been in a corrections facility, has battled addiction their entire adulthood as many of our clients have, you don’t need to get into details about what’s happened to them. You understand those life experiences suggest they have experienced trauma. You see it playing out in symptoms—anxiety, depression, addiction—and even more specific things like having a hard time building relationships with people in power, having a hard time making appointments, or taking meds on a specific regimen. These things might not seem that complicated to their providers, but for those who’ve experienced trauma these details can become really difficult.

Each of us works with about 20 to 25 patients. We initially meet clients in the clinic. Then what I like to do is meet clients wherever they’re staying—in their homes, friends’ houses, homeless shelters, camping on the streets. We might go out for a walk, do something to break down that power dynamic that might happen in an office with someone sitting across the desk from me.

Then if patients want, I attend their specialist appointments. We are there as an advocate for the client and help guide the discussion. I do a lot of prep beforehand with the client: We go over what’s going to be discussed and ask them about their needs and what they want to get out of it. Afterwards we debrief: I’ll ask what did you hear? What’s your understanding of what just happened? Then I bring information back to the primary care providers in the clinic, looping them in on the visits and other details, like what the clients’ home life is like, what other stressors they might be experiencing.

One of the clients I worked with was homeless and living on the streets. This person had battled alcoholism for decades, and had Crohn’s disease and had to take care of a colostomy bag, Because of the circumstances, the patient couldn’t really control diet, and didn’t have any place to have supplies delivered or take care of basic needs. This person was in the ED a couple times a week for colostomy care.

When we first met I focused on basic needs: can we get your supplies delivered? How can we troubleshoot your bathroom situation? As our relationship developed, I learned why this person wasn’t coming to the primary care provider’s office. This member had experienced a significant trauma—their partner had recently died tragically and they’d thus lost their only housing in years and many of the social supports that were connected to the partner. Making matters worse, while living on the streets they had been attacked numerous times and lost all their possessions including colostomy supplies. 

Understanding what had happened helped me brainstorm solutions. We ended up having supplies delivered to a local homeless shelter, got food vouchers to get healthier foods at a farmer’s market, and then got the member into drug and alcohol treatment—and that was a big step. But we couldn’t really start talking about that until their basic needs were met.

The other part of my job is working with primary care doctors to help them understand patients with such complex needs. We often do a lot of prep work with physicians in terms of managing expectations about where our clients are at. For example they may be really concerned about someone’s A1c level. But when they come into an appointment not knowing this person only gets their food from a food pantry, or runs out of their food stamps the first week of month, talking about counting carbs isn’t going to get us anywhere.

Our work is different from a clinic-based social worker because we’re not stuck in the clinic; we are out in the community with people. We can take a broader look of what’s going on with a person. That’s part of the trauma-informed approach: instead of looking at the problem list—how to fix that person—it’s taking a deep breath and wondering what’s happening in this person’s life and how can we help.


 


1 K. Vartanian, S. Tran, B. Wright et al., “The Health Resilience Program: A Program Assessment,” The Center for Outcomes Research & Education, January 2016.

 

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