Patients’ social services needs met at Jurupa Valley Community Health Center with new integrated service model
Staff from Riverside University Health System and the Safety Net Institute at RUHS’ Jurupa Valley Community Health Center
Over the summer and fall of 2023, four patients in very different places in their lives visited their primary care physicians at Riverside University Health System’s (RUHS) Jurupa Valley Community Health Center (the Center).
Unexpectedly, they walked out of the Center with much more than medical advice, prescriptions, and dates for follow-up tests and visits. They exited with solutions to what mattered to them on that day. A married couple, both over 75, completed power of attorney documents. A teenager who is pregnant enrolled in a free two-year program where a nurse visits the home regularly to help ensure a healthy pregnancy and baby; an on-site Raising a Reader program; and a supplemental nutrition program. And a middle-aged man facing unemployment received actionable information on where to receive free job skills training locally and completed an application for a Social Security number.
Before Riverside County began integrating social services into physical and behavioral health care at the Jurupa Valley Community Health Center in 2023, patients with low incomes faced several barriers to meeting many of their pressing health-related social needs, such as housing. For example, they would often have to travel to several locations, stand in a variety of lines, and navigate multipage, often English-only applications online.
“You could feel other issues and needs under the surface, but we didn’t have an avenue to address them. It left you with that feeling that there is more I can do [for the patient], but I don’t have a way.”
– Dr. Edward Bacho, medical program director, Riverside University Health System
Before integration
Patients struggling to obtain non-medical services impacting their health have long gnawed at Dr. Edward Bacho, medical program director, RUHS, who works at the Center. Bacho and 90 other health care workers see more than 200 patients daily at the Center for primary, perinatal, behavioral, dental, and podiatry care. The overwhelming majority of the Center’s patients are covered by Medi-Cal or uninsured, and many are undocumented.
Describing appointments with patients prior to the clinic’s social-medical integration, Bacho said, “You could feel other issues and needs under the surface, but we didn’t have an avenue to address them. It left you with that feeling that there is more I can do [for the patient], but I don’t have a way.”
Bacho and other RUHS health care workers were acutely aware that these factors, such as employment and nutritious food, can drive as much as 80% of health outcomes in their patients’ lives. For years, RUHS was eager to address these highly influential factors, also known as social determinants of health.
Pioneering integrated service delivery in Riverside County
Bacho and other RUHS staff wanted to eliminate the time and technical obstacles (e.g., missing work, online portals) to obtaining social services that patients frequently face. They envisioned Jurupa Valley patients only having to walk into the Center to have their various needs addressed on-site and on the same day.
RUHS partnered with Riverside County departments to strategize on how to build out integrated service delivery. These departments include (but are not limited to) the Department of Public Social Services (DPSS), Office on Aging, and First 5 Riverside (focused on the health and development of children ages 0 to 5 years old and their families).
“We pull on each other’s experience to make it happen for the patient.”
– Shannon Bates, social services supervisor, Department of Public Social Services
One of the initial results of this multi-year planning process was physically uniting clinical care and non-clinical services by establishing a Family Resource Center (FRC), managed by First 5, alongside the clinic. The FRC was placed near an existing small grocery store; Women, Infants, and Children (WIC) office; and Office on Aging, also adjacent to the clinic. RUHS and the county wanted to serve and support patients at all stages of life.
This consolidation also seeks to break down longstanding silos between agencies so patients can more easily get the care and services they need in one place. Funding for the integrated service delivery has been supplied by the county’s board of supervisors and health and human services departments.
In addition to existing staff, four new positions were created to support the integrated service model: three resource specialists embedded on the clinic side and a social worker on the FRC side. Working in sync, these employees serve as patients’ advisors and advocates, taking direction from them on the services they want, whether helping with finding a job or parenting support.
“We pull on each other’s experience to make it happen for the patient,” said Shannon Bates, social services supervisor, DPSS. Part of this tight collaboration occurs during daily huddles when employees from the clinic, the FRC, and agencies gather to discuss and track their collective progress in meeting each patient’s needs.
The foundation for RUHS’ integration model: the whole person health score
To gauge how a patient is progressing in having their social needs met, these teams must first know the patient’s overall starting point, which isn’t always captured in clinical metrics. So, how can health care workers and other professionals measure and track health-related factors, such as social connections?
In 2016, RUHS physicians and researchers grappled with this question as they strove to better understand and improve patients’ quality of life. After extensive research and beta testing, the team developed and rolled out a groundbreaking screening tool called the whole person health score, recognized in a 2022 New England Journal of Medicine publication.
The Center’s considered approach has paid off: 80% of patients have completed the whole person health score since the launch of integrated service delivery in May 2023, up from 38% before the resource specialists came on board.
How it works: patients at the Center answer the screening tool’s 28 questions in six categories, from socioeconomics to physical and emotional well-being. They receive score results as green, yellow, or red for each category. This simple visualization makes it easy for patients, their RUHS providers, and other staff to understand the level of need and work together to close gaps and improve scores. It’s the guiding light for the multidisciplinary staff and the focus of conversation with patients.
How patients experience integrated service delivery
The day before a patient comes to their medical provider at the Center, a resource specialist phones them about completing the whole person health score if they haven’t already done so.
If the patient is interested, the specialist completes the questions with them over the phone. If not, the patient can complete the screening on an iPad when they arrive for their medical appointment. In pods just off the waiting area, specialists discuss the purpose of the whole person health score with patients to increase understanding, safety, and comfort. These conversations are critical given the sensitive nature of some questions and many patients’ undocumented status.
The Center’s considered approach has paid off: 80% of patients have completed the whole person health score since the launch of integrated service delivery in May 2023, up from 38% before the resource specialists came on board.
For patients whose scores indicate they need more assistance (i.e., a yellow score), the specialists discuss the results and what might be causing them. They also normalize the results. “We all have challenges and needs,” said Bates.
Next, Bates and other specialists engage in motivational interviewing, asking, “What do you want to pursue? How would you like to move forward?” Taking direction from the patient, the specialist organizes resources and offers support to help them make concrete headway on achieving their goals there and then.
“A referral, in and of itself, is not enough.”
– Michelle DeArmond, executive director, RUHS
For patients needing services provided by WIC or the Office on Aging, the specialist walks them over and introduces them to the appropriate agency employee. However, the specialist is not just passing the patient along. They continue to take ownership of the patient’s progress, ensuring they get what they need.
Beyond referrals
For patients with the highest needs (i.e., red scores) and who want to make progress, the resource specialists walk with them from the clinic to the FRC side of the building and introduce them to Rosalba Mejia-Torres, social worker, First 5 Riverside.
“For the patient, we’re not saying, ‘Go out the door, turn right, when you see the sign,’ or ‘just call this number,’” said Jill Kowalski, regional manager, First 5 Riverside.
Many at RUHS feel the referral-only approach falls short. “A referral, in and of itself, is not enough,” said Michelle DeArmond, executive director, RUHS.
In health care and social services settings across the country, many patients drop off after receiving such directions due to uncertainty, confusion, shame, or the need to attend to something else. However, the resource specialists’ warm hand-offs to agency staff or Family Resource Center staff have kept patients on the path to having their needs met.
“I treat clients as equals. I relate to them. I come from the same background and struggles. And when you open that door, and they know you care, they’re going to keep coming back.”
– Rosalba Mejia-Torres, social worker, First 5 Riverside
Once Mejia-Torres sits down with the patient, she applies her knowledge and problem-solving skills to their unique situation. She may coordinate with agency staff on-site to enroll the patient in a food stamp program or Medi-Cal or connect with external organizations to arrange a security deposit for housing or translate a document into Spanish. Like others at the Center, her mindset is fixed on resolving (or overseeing the resolution of) what patients require that day.
“I don’t think there’s anything that I would not go out of my way to help a client with,” said Mejia-Torres.
100% show rate for follow-up appointments
Although Bates, Mejia-Torres, and others resolve most patient-directed non-clinical items on the spot, some patients have more time-consuming needs. Avoiding eviction or creating a resume can require follow-up visits.
“We have never had a patient that has been scheduled for a follow-up appointment not come in,” said Kowalski. As of December 2023, everyone has shown up, a rare achievement.
Kowalski attributes this 100% show rate to successful execution. “What resonates with clients is when something gets done. The ‘my application is completed, we did it right here, it’s done!’”
What also explains the return visits is the empathetic approach that builds trust, says Mejia-Torres. “I treat clients as equals. I relate to them. I come from the same background and struggles. And when you open that door, and they know you care, they’re going to keep coming back.”
In addition to high patient participation in follow-up appointments and whole person health score screening rates, the overall health of patients treated at the Center since the integrated service model rolled out, as measured by their health score, is trending in a favorable direction.
What’s next
In 2024, RUHS and the county human services departments plan to spread this integrated service delivery model to additional RUHS community health centers and non-clinic locations, and ultimately, increase Riverside County’s health places index score.
“The goal is to make integrated service delivery the way we do business everywhere, fully integrated throughout our system and the way we exist,” said DeArmond.
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1. Subject to the terms and conditions contained in this agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. Applications are available at the NUBC website, http://www.nubc.org/.
3. The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER
The AHA hasn’t reviewed and isn’t responsible for the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessary represent the views of the AHA. CMS and its products and services aren’t endorsed by the AHA or any of its affiliates.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES
UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice to you if you violate the terms of this agreement. The AHA is a third-party beneficiary to this agreement.
CMS DISCLAIMER
The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
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