SNI Forward, January 2024

Only several weeks into the year and many of our systems’ leaders have already come together to share strategies, learn from experts and each other, and explore lessons learned to truly better patients’ lives in 2024.

Recently, 14 California public health care systems met to advance strategies that embed equity throughout their organizations as part of SNI’s Racial Equity Community of Practice (CoP). These members are participating in the second phase of the CoP, which will run for two years and builds on the first phase’s momentum. You can watch and read about how system leaders in phase one think about (and act on) racial equity, what advice they have for other systems around equity work, and more here.

On January 24, nearly 120 leaders from public health care systems and local Medi-Cal managed care plans gathered in Burbank as part of SNI’s collaboration to strengthen partnerships between systems and plans. This first convening, run in collaboration with the Local Health Plans of California (LHPC), focused on quality and equity.

Leaders from public health care systems and local Medi-Cal managed care plans gather at an SNI event in January 2024.

Speaking of collaboration, read below and here for a groundbreaking example of medical and social services integration on-site at Riverside University Health System’s (RUHS) Jurupa Valley Community Health Center. You’ll learn about why this new approach has been a hit with patients.

Lastly, as we move into the new year, systems continue their work in the Quality Incentive Pool (QIP), a pay-for-performance program that provides critical funding for public health care systems if they meet ambitious improvement targets on clinical measures. SNI convenes system leaders to share effective strategies to succeed in QIP, from improving cesarean birth rates to follow-up with patients after an ED visit for mental illness.

Below, you can access the recap of SNI’s three-part webinar series focused on helping members prepare for new QIP priority measures in 2024. You’ll also find videos of the six systems that won the 2023 Quality Leaders Awards and their inspiring work.

Patients’ Social Services Needs Met at Jurupa Valley Community Health Center

When you think of patients meeting with their primary care physicians at a community health clinic, you don’t usually think of them as leaving with completed applications for a Social Security number and legal documents appointing health care agents.

But at Jurupa Valley Community Health Center, part of RUHS, patients currently receive such help, and much more, thanks to the recent integration of social services into its physical and behavioral health care.

Staff from Riverside University Health System and the Safety Net Institute at RUHS’ Jurupa Valley Community Health Center.

“We pull on each other’s experience to make it happen for the patient,” said Shannon Bates, social services supervisor, Riverside County Department of Public Social Services. Part of this tight collaboration occurs during daily huddles when employees from the clinic, the newly built Family Resource Center, and on-site social services agencies (WIC, Office on Aging) gather to discuss and track their collective progress in meeting each patient’s needs.

So far, 100% of patients return for follow-up appointments with resource specialists and social workers. Read our blog about who and what is shaping this successful integrated care model, from social worker Rosalba Mejia-Torres to the whole person health score.

Winners of the Quality Leaders Awards and Their Work

At the CAPH/SNI annual conference last month, six public health care systems were recognized for their inspiring approaches to advancing equitable and high-quality care. The winners of the 2023 Quality Leaders Awards are:

Top Honor – UC San Diego Health

UC Health Milk Bank: Increasing Donor Milk Access in California

Despite strong evidence to support the use of pasteurized donor human milk (PDHM) for vulnerable infants, 20% of California NICUs do not have PDHM programs. This access disparity falls along racial and socioeconomic lines, leading to poorer health outcomes for infants of color. UC San Diego Health started the UC Health Milk Bank (UCHMB), to solve disparities in access to high-quality pasteurized donor human milk in NICUs. The program has since expanded donor milk access by opening the first accredited milk bank in Southern California under the Human Milk Banking Association of North America. In addition, UCSD Health worked with stakeholders to revise the 2022 Medi-Cal PDHM policy, making it easier for providers to prescribe PDHM when medically necessary, and established the Bridge Milk Fund to assist financially insecure families in accessing PDHM.

Equity – Zuckerberg San Francisco General

Behavioral Emergency Response Team: A Trauma-Informed Approach to Support Our Patients and Nonpsychiatric Medical Colleagues

Zuckerberg San Francisco General (ZSFG) established the Behavioral Emergency Response Team (BERT) program in 2018 with the goal of de-escalating behavioral health emergencies to create a safer and calmer environment for hospital patients and staff. BERT approaches these situations with trauma-informed care, focused on 24/7 support, verbal de-escalation, and patient engagement. BERT has played a vital role in reducing use-of-force incidences; 84% of BERT Activations were completed without law enforcement present. Due to the program’s success, it received permanent funding and expansion in 2022.

Care Redesign – Los Angeles County Department of Health Services

Advancing Equity and Reducing Disparities in Care by Expanding Access to Genetic and Genomic Testing in the Safety Net

Advanced genetic testing offers significant promise to improve care for many life-threatening diseases. However, inequities in access to genetic testing and counseling among racial and ethnic minorities threaten to exacerbate disparities in health care outcomes. To increase appropriate care delivery for genetic diseases, the Los Angeles Department of Health Services (DHS) has established a multidisciplinary genetics and genomics optimization program to develop and align best practices for screening, testing, and counseling of conditions with genetic basis of disease to improve outcomes and reduce care gaps. Since its creation, the program has improved on several of its goals, including improving clinical guidelines, hereditary cancer risk assessment and testing, and streamlined patient navigation.

Innovation – Santa Clara Valley Medical Center

Integrated Transitions of Care Model for Vulnerable Populations

Patients with cognitive impairments reentering communities after incarceration remain at high risk for poor health outcomes and often require extensive care coordination and support. The Integrated Care Team (ICT) program by Santa Clara Valley Medical Center provides complex care coordination to these patients post-custody release by establishing access to a medical home and addressing social determinants of health. By using a patient-centered approach, including case meetings and patient outreach, Santa Clara Valley Medical Center can better support the individual’s reintegration into the community. This program has resulted in increased primary care physician visits and court system compliance and decreased Emergency Department utilization and custody encounters for patients.

Population Health – UC Davis Health

Advance Care Planning and Mandatory Surprise Question

UC Davis Health initiated a comprehensive effort to enhance Advance Care Planning (ACP) in both inpatient and ambulatory settings by introducing their predictive Mandatory Surprise Question (MSQ) in January 2020. Admitting providers assessed whether they would be surprised by patients passing away in six months. “Not Surprised” patients exhibited a 6-fold higher mortality rate, more palliative/hospice referrals, longer stays, and increased ICU admissions. This predictive tool led to increased Advance Care Planning (ACP) rates, greater use of palliative care, and higher inpatient hospice enrollment. Overall, it has reduced unnecessary medical interventions and health care spending.

Honorable Mention – Kern Medical

Shelter Integrated Recuperative Care Facility

The Recuperative Care Facility program by Kern Medical was created to help alleviate the strain on the hospital caused by the rising homeless population. The facility provides non-acute care, including communal and isolation rooms, with the goal of lowering health care expenses, enhancing patient outcomes, and reducing the risks homeless patients face during their recovery. Kern Medical is also integrating medically assisted treatment for those in the homeless population who are willing to seek help. Since its official opening on July 1, 2023, the facility has been able to accept 20 referred patients who have stayed for a total of 235 bed days.

Webinar Series Recap on Meeting QIP Targets

In 2024, three Quality Incentive Pool measures moved to the priority measure set: the Cesarean Birth Measure; Follow-Up After ED Visit for Substance Use Measure; and Follow-Up After ED Visit for Mental Illness Measure. In the fall and winter of 2023, SNI’s three-part webinar series focused on helping members prepare for these new PY7 priority measures. In this webinar series recap, you can read about promising practices and strategies that San Joaquin General Hospital’s Family Maternity Center, Riverside University Health System, and UC San Francisco have implemented regarding these measures.