Welcome
I usually start SNI’s first newsletter of the year with a message of optimism and hope – reflecting the time when many of us typically set resolutions and contemplate better versions of ourselves and the new challenges we want to tackle, both professionally and personally.
Yet, 2025 has started off in ways that were difficult to imagine even a month ago. Our colleagues in Southern California continue to deal with the devastating impacts of the wildfires. Not only are they responding as care providers for those injured, those managing respiratory conditions, and those who need mental health support in the wake of tremendous loss and grief, but they are also supporting staff who have themselves lost their homes. It’s a level of tragedy that’s difficult to comprehend.
On top of this, safety net providers are facing mounting – and pressing – uncertainty about the future of Medicaid financing, changes to which could have disastrous impacts on California’s public health care systems and their patients.
In any other message, I would transition here to say, “But California’s public health care systems are resilient.” They are – they show up every day, in all kinds of ways, and all of us at SNI are honored to work for them. And yet, shifting so quickly to a message of hope and a call for optimism doesn’t feel like it honors what so many of us are feeling these days. So instead, I will just offer that I hope we can all take care of each other, in small and big ways. A colleague from one of our public health care systems recently shared, “With community, we can overcome anything.” I believe that’s true, and I look forward to building community with all of you.
I will also end my message with a reminder of some good news from the CAPH/SNI Annual Conference in December, where we recognized the winners of the Quality Leaders Awards (QLA). These awards honor systems that created entirely new ways to improve health and well-being. Below, you will find short videos and highlights of their exceptional work.
Giovanna Giuliani
Executive Director
California Health Care Safety Net Institute
P.S. After the QLA videos and summaries, you can explore successful initiatives co-designed with patients and communities for equity, our new 2025 Quality Improvement Pool (QIP) Fact Sheet, and more.
Winners of the Quality Leaders Awards and Their Work
The winners of the 2024 Quality Leaders Awards are:
Top Honor: Riverside University Health System
Award: Transforming our Partnership for Student Success
To address behavioral health needs among students, Riverside University Health System (RUHS) partnered with a local school district to implement the Transforming our Partnerships for Student Success (TOPSS) program. This initiative features tiered behavioral health services, universal holistic health screenings, and onsite support.
Key Outcomes (2020–2024):
- 7,626 students assessed across seven schools, with 23.9% identified as having serious health needs.
- 4,510 students received behavioral health services from January 2022 to June 2023.
- 93,544 units of social services (e.g., food, clothing, housing assistance) provided from August 2022 to May 2024.
- Students with concerning behavioral health needs decreased from 15% in 2020 to 7% in 2023.
Care Redesign: Alameda Health System
Award: Providing Quality Pediatric Primary Care in the Safety Net
The Alameda Health System (AHS) Department of Pediatrics and Quality Improvement implemented a comprehensive strategy to enhance pediatric care across its four federally qualified health centers, focusing on addressing healthcare disparities and barriers to well-child visits (WCV) and immunizations. Key interventions included implementing gap alert systems in the electronic medical record (EMR), restructuring scheduling templates and rules, sending text reminders for checkups, and educating patients about free transportation options.
Impact (2021–2023):
- Improved all 10 pediatric quality metrics, most exceeding the 90th percentile benchmark.
- Doubled WCV completion rates for Black patients to 42%.
- Reduced disparities between Black and Hispanic patients
- WCV rates gap decreased from 11% to 4%.
- Adolescent immunization gap reduced from 35% to 10%.
Innovation: Contra Costa Regional Medical Center
Award: A3 Crisis Response: Anywhere, Anyone, Anytime
In response to community demands for compassionate and comprehensive behavioral health services, Contra Costa Regional Medical Center (CCRMC) collaborated with advocates for mental health and the unhoused, providers, and individuals with lived experiences to reimagine crisis care. This effort led to the creation of the A3 Community Crisis Response Program, ensuring access to professional help anytime, anywhere in the county.
Key Features and Impact:
- 24/7 dedicated crisis phone line providing immediate support.
- In-person crisis response for individuals in need.
- Since 2023, the program has supported over 14,400 people via the phone line and provided in-person crisis support to 2,237 individuals.
Equity: San Francisco Health Network and Zuckerberg San Francisco General Hospital
Award: Heart Failure Readmission Rate Reduction
San Francisco Health Network (SFHN) and Zuckerberg San Francisco General (ZSFG) launched a heart failure population health initiative leveraging machine learning and artificial intelligence within their electronic health record (EHR). The program aimed to reduce heart failure hospitalization and readmission rates, close equity gaps, and retain at-risk pay-for-performance funding.
Key Strategies:
- Standardized care with EHR decision support addressing medical and social determinants of health.
- Deployed machine learning tools for collaborative heart failure care teams.
- Developed a specialized clinic addressing concurrent heart failure and substance use.
Outcomes:
- 13% reduction in 30-day all-cause readmission rates.
- 6% decrease in one-year heart failure mortality.
Equity gaps eliminated for Black/African American patients compared to the general heart failure population
Population Health: Ventura County Health Care Agency
Award: Public Health Care System and Local Health Plan Collaboration Improves Population Health for Medi-Cal Patients
The Ventura County Health Care Agency (VCHCA) partnered with Gold Coast Health Plan (GCHP) to improve shared quality metrics for Medi-Cal members. This collaboration combined VCHCA’s outreach and clinical services with GCHP’s financial support to maximize impact. VCHCA and GCHP worked together to share more complete quality data, expand clinic services, and enhance access to preventive care.
Key Initiatives and Results:
- Provided gift cards to incentivize patients to complete preventive services.
- Extended clinic hours to weekends and evenings to reduce barriers to care.
- Secured GCHP funding for point-of-care machines (HbA1c, lead, hemoglobin) to streamline diabetes care.
- Achieved a 21% increase in well-child visits and closed care gaps for over 5,000 Medi-Cal members in 2023.
Co-designing for equity
As members of our Racial Equity Community of Practice focus on integrating equity into their quality improvement and patient and family engagement efforts, they and others recently gained insights from other health systems’ successful co-design experiences.
At our CAPH/SNI annual conference’s health equity panel last month, Dr. Malini Nijagal, a panelist from Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Health, and Team Lily, shared how they prioritize patient autonomy. For example, Team Lily patients – not providers – set the priorities for each appointment.
Another panelist, Jyesha Wren, nurse midwife and founding director of Alameda Health System’s (AHS) BEloved BIRTH Black Centering, discussed her program’s model of group perinatal care by, for, and with Black people. The program has achieved stunning results: babies in the BEloved BIRTH program had a 5.6% preterm birth rate compared to 11.5% among non-program Black babies at AHS.
View presentations from these health equity panelists, including Dr. Pamela Riley, chief health equity officer and assistant deputy director of quality and population health management, California Department of Public Health, and Dr. Palav Babaria, chief quality officer and deputy director of quality and population health management, California Department of Health Care Services.
Drs. Riley and Babaria outlined how they are listening to and co-designing with people who receive Medi-Cal and encouraged public health care systems to invest in equity initiatives like Team Lily and BEloved BIRTH Black Centering.
New quality measures and engagement techniques
2025 Quality Incentive Pool Fact Sheet
For the millions of individuals enrolled in Medi-Cal, public health care systems strive to improve care quality and equity. At the heart of what drives this progress – in a systematic and sustainable way – is California’s Department of Health Care Services’ Quality Incentive Pool (QIP).
QIP is a managed care directed payment program that provides critical funding to health systems when they achieve ambitious targets on a number of measures across multiple domains of care.
In SNI’s 2025 QIP Fact Sheet, you can view this year’s priority measures, including chronic disease management; elective measures; and informational measures. We look forward to continuing to help our health systems meet these reporting requirements.
How to engage patients hesitant about vaccines
In a SNI-hosted webinar, Dr. George Su and Lisa Vu from UCSF shared the HEAR technique to respectfully engage with people hesitant about getting vaccines. The goal is not to convince or direct patients, but rather to listen to their concerns and offer information they might find useful for making an informed decision. You can access the one-page recap of the webinar, slides, and recording here.