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Improving Care for Patients with Chronic Diseases

Clinics

HANFORD – Some diseases, such as diabetes, require more attention than others. To help community members manage these chronic conditions and live their best life, Adventist Health launched the Complex Chronic Care clinic at Adventist Health / Community Care – Hanford.

The clinic manages the care of patients who can’t afford to see a specialist and who don’t have a primary physician but are in desperate need of care.

This need was discovered in 2015, when staff noticed the same patients coming in and out of the Emergency Department with the same complex health issues.

“We’re taking the sickest patients and managing them in a team-based approach with other primary care physicians and specialists,” says Dr. Raul Ayala, family medicine physician in Hanford and Selma. “But first, we have to find out what’s causing their illnesses.”

Dr. Ayala gives an example of a Complex Chronic Care patient:

A 27-year-old schizophrenic patient has kidney failure and poorly managed diabetes and is going blind. He has no primary care doctor and can’t keep a clinic appointment because he lives in a foster home and has no transportation. As a result, he stops going to dialysis and is in and out of the Emergency Department. Now, enter the Complex Chronic Care clinic, which helps manage this patient’s care, provides transportation through Adventist Health’s free shuttle service, coordinates with his insurance company and sets up a Home Health visit so a nurse can go to his foster home and give him an insulin shot.

“It’s complex because we’re looking at other aspects of the disease, such as the psychosocial aspect, that are affecting a person’s health and well-being,” says Dr. Ayala.   

A team of 10 staff members are now dedicated to managing Complex Chronic Care, including two physicians, four physician assistants, a licensed vocational nurse, medical assistant, clinical manager and transition care guide. 

“We’re not trying to replace what’s being done by the primary care physician,” says Dr. John Zweifler, who also cares for patients at the clinic. “We just want to help out when these patients have complex care issues that need to be addressed.”

For more information about scheduling Complex Chronic Care patients, please call Community Care – Hanford, (559) 537-0250.