Like many health systems, Roseville, California-based Adventist Health is pursuing a mission to make healthcare accessible for everyone. Accomplishing this vision will require strategic investments in care provided outside the walls of its hospitals and clinics, said Shelly Trumbo, Adventist’s vice president of wellbeing. That’s why the health system announced partnership with Emcara Health last week.

Emcara Health is a national provider group that serves about 50,000 patients using value-based advanced primary care models. GuideWell’s population health analytics subsidiary PopHealthCare launched the company last October. Emcara’s care teams treat patients where they are — whether it be in their homes, in shelters or on the street — and help coordinate other in-person care as needed. 

Trumbo said Adventist’s partnership with Emcara will advance the work the health system is doing through its participation in the California Advancing and Innovating MediCal (CalAIM) program, which gives providers state funds to improve health outcomes among Medi-Cal enrollees by broadening care delivery models.

There are some populations, such as the unhoused, that brick-and-mortar healthcare providers will never be able to reach. To address this problem, Emcara partners with health systems “as an extension of their capabilities,” the company’s CEO, Eric Galvin, said in an interview.

Emcara’s care teams comprise complex care physicians, field nurses, advanced practice providers, community health workers and care coordinators. The team also collaborates with pharmacists, dietitians, physical therapists, social workers and palliative care physicians to establish holistic care plans for its patient base.

For its partnership with Adventist, Emcara is deploying its care teams into California’s Central Valley to conduct primary and preventive care visits. These care teams assess not only a patient’s health, but also their environment. 

“The partnership focuses heavily on social determinants of health, because these individuals by and large are not always going to be in a home,” Galvin said. 

After these initial visits are completed, Galvin said Emcara’s care teams will act as the “air traffic controller” to ensure patients can access any Adventist specialty care they may need. They will also direct patients to community resources, such as health food distribution programs or organizations providing free transportation to healthcare visits, to help improve their social determinants of health.

“Adventist recognizes that healthcare spending in America falls short in investing in the broader spectrum of the determinants of health,” Trumbo said. “This partnership will respond to the new opportunities through CalAIM, allowing us to shift care upstream and meet people where they are.”

To measure the success of the three-year partnership, Adventist will track metrics such as graduation rates (when Emcara’s services are no longer needed for a patient) and whether emergency room utilization and hospitalizations are decreasing. The health system will also track the improvement of social determinants of health, such as the Medi-Cal population’s access to housing and healthy food, according to Trumbo.

Emcara will first track the number of patients it is able to engage. It will also look at metrics associated with patients’ health outcomes, such as how rates of medication adherence are changing or the number of patients who have follow-up appointments with Adventist specialists.

Galvin pointed out that while Emcara’s partnership with Adventist focuses on serving the Medicaid population, it could evolve in the future to include the Medicare Advantage population or those that have bought insurance coverage from state exchanges through the Affordable Care Act.

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