Young patients transition into adulthood with Complex Care Management program

Jul 9, 2020


The Complex Care Management program at Adventist Health in the Central Valley has expanded with the help of a new partnership with Valley Children’s Healthcare, bringing the expertise of a multi-disciplinary team of healthcare workers to young patients with childhood onset conditions as they transition into adulthood.

For Debbie Young, the Complex Care Management program filled the gap in the medical care of her son, Michael. Born with a congenital heart defect, Michael has lived his entire life with multiple medical conditions requiring specialized care.

“It’s so nice to know you can go to one place where they can provide services so quickly,” said Young. “This is so needed in the valley.”

The Complex Care Management program, formed in 2015, treats patients with two or more comorbidities who are at a higher risk of hospital readmissions and emergency department visits, while also simultaneously susceptible to inconsistent primary care. Patients are paired with a full-time provider, nurse, care coordinator, pharmacist and pastor who work together to improve the patient’s health.

“Because of this collaborative team-based approach, we are better equipped to treat the patient’s conditions and help keep them out of the hospital,” said Dr. Raul Ayala, medical officer for Adventist Health in the Central Valley and director of the Complex Care Management program.

Recently, Adventist Health developed a partnership with the Transition Clinic at Valley Children’s Hospital to expand the program. The Transition Clinic collaborates with Valley Children’s specialty care centers, supporting their chronically ill patients’ preparation, healthcare provider and many other needs that arise in the process.

“Research shows that patients must establish with adult primary care to maximize their potential,” said Dr. Patrick Burke, program director of Valley Children’s Transition Clinic. “Complex Care provides a new option to meet this goal, whether it is a type 1 diabetic young man who never followed with a pediatrician or a profoundly disabled woman with cerebral palsy who has followed with Valley Children’s Charlie Mitchell Clinic for complex pediatric care. Through this collaboration, patients like these can seamlessly transition into the Complex Care Management program, where they will continue to receive specialized care into adulthood.”

“This partnership is evidence of what we can accomplish through friendship and collaboration between two healthcare organizations,” said Dr. Ayala. “It truly is a blessing to work with others and care for at-risk patients who need our help the most.”

Michael, now 33, is one of more than 20 patients who has transitioned care from pediatric primary care to the fully staffed Complex Care Management program based in Hanford and Selma. Before the transition, patients and their families meet their new care team, are provided with instructions on what to expect moving forward and are scheduled monthly check-ins and appointments. In some cases, they may still see Valley Children’s specialists into adulthood.

“We already have two appointments with specialists that we’ve been waiting for,” said Young. “This is a wonderful partnership and has filled the void from us having to go to the emergency department.”