Ventura County Health Care Agency
Ambulatory Care Redesign
Contra Costa Health Services
Zuckerberg San Francisco General Hospital and San Francisco Health Network
Los Angeles County-USC (LAC+USC) Medical Center
Top Honor: Kaiser Permanente Clinical Systems Development Award
Top Honor - Los Angeles County-USC (LAC+USC) Medical Center
Our neighborhoods influence our behaviors and affect our health in profound ways — social and economic factors are linked to physical and mental health disorders. The population of Los Angeles County has tremendous social and behavioral needs as demonstrated in the 2015 Los Angeles County Health Survey. For example, 16% of adults admitted to binge drinking, 9% endorsed being depressed or having a medical diagnosis of depression, 29% of households <300% below the federal poverty level endorsed food insecurity, nearly 50% endorsed living in stressed housing conditions, and 15% of women endorsed physical intimate partner violence.
To better meet the needs of patients and improve health outcomes, the Primary Care Adult Clinics at Los Angeles County-USC (LAC+USC) Medical Center implemented an integrated behavioral health and social services program into primary care clinics. LAC+USC are two of the largest primary care clinics in the Los Angeles County Department of Health Services (LADHS) serving a population of nearly 40,000 patients (70% in Medi-Cal managed care).
Based on the IMPACT model of collaborative care, this program consists of universal screening for social and behavioral conditions and improved access to behavioral, mental, and social services by integrating these services into primary care. Delivering evidence-based interventions to manage social and behavioral conditions is also a critical component. The traditional medical team — nurses, clerks, and providers — were extensively trained in screening, diagnosis, management, and referral and tracking outcomes for social and behavioral conditions. This training has made the referral process easier and more efficient since any member of the care team can easily refer a patient to another member. The entire patient population now has access to social, behavioral, and mental health service providers.
Within two years, LAC+USC doubled their patient capacity for psychiatry and had a fourfold increase in visit capacity for social work. Nearly 20% of patients who screened positive for food insecurity were enrolled into CalFresh. A statistically significant improvement in diabetes, blood pressure, and depression severity in patients seen by social services or psychiatry was also documented. Further, hospitalizations decreased by 40% and emergency room/urgent care utilization among patients seen by social services or psychiatry decreased by 20%.
Due to the success of this program, LAC+USC’s model serves as the basis for the spread of integrated services across all of LA County Department of Health Services. Next year, the county aims to staff behavioral health teams at every primary care clinic across LA County Department of Health Services. The program will be able to reach hundreds of thousands of patients empaneled to LA County primary care clinics, and has been recognized by various local, state, and national organizations.
Performance Excellence - Zuckerberg San Francisco General Hospital and San Francisco Health Network
In 2017, a large multidisciplinary team from Zuckerberg San Francisco General Hospital (ZSFG) and San Francisco Health Network (SFHN) initiated a novel approach to deliver holistic care to Emergency Department (ED) patients with complex social needs. Previously, one-third of inpatients admitted through the ED stayed in the hospital less than two days. A review of short-stay inpatients showed a pattern of low medical acuity and high social complexity. Hospitalizing patients for social needs was not addressing patients’ fundamental determinants of health or meeting the internal strategic goals of ZSFG and SFHN.
To address this issue, a multidisciplinary team partnered to provide ED patients and providers with safe alternatives to hospitalization by assessing and treating patients’ social illnesses. Using LEAN improvement tools, the team developed 10 initiatives, ranging from a new ED social medicine consult service to direct linkage for ED patients to transitional housing.
Since January 2018, the team served over 1,000 patients with complex socio-medical needs and prevented over 180 admissions and 30 readmissions. The ED re-visit rate reduced by 10% and the inpatient length-of-stay also decreased. Individual patient outcomes have been transformative — the program has helped many surmount homelessness, engage in substance use treatment, and connect with medical and social services in a community setting.
This work represents a profound change in how ZSFG and SFHN care for vulnerable patients — a multidisciplinary approach that incorporates complex social and medical needs in equal measure. Many clients who experience organ failure, substance use, homelessness, and mental illness, have little or no social support. ZSFG’s integrated, longitudinal treatment plan using communication, care coordination, and complex care interventions brings profound success stories each week — shifting these vulnerable patients into stable community living, integrated with primary care and engagement in outpatient treatment.
The health system is identifying opportunities to spread this work including collaboration with the social medicine team to help address patients with high social needs who are not hospitalized, known as ED super-utilizers. This model of care will help ZSFG and SFHN provide a new level of excellence in care for the residents of San Francisco.
Data-Driven Organizations - Contra Costa Health Services
Contra Costa Health Services (CCHS) provides comprehensive behavioral, medical and social support services to vulnerable patients throughout Contra Costa County. This broad spectrum of care includes standard clinical services, public health outreach, homeless and housing support, and extensive behavioral health services provided through multiple pathways. CCHS saw an opportunity to leverage the well-established electronic health record (EHR) system to improve care coordination across county departments and provide more integrated services to patients.
For medical providers with limited 15 minute follow-up visits, the fragmented, siloed record systems were a problem. Providers were unable to view information from public health nurses, home visitors, or housing case managers’ attempts to secure permanent housing for patients. This lack of coordination resulted in decreased patient satisfaction and duplication of services. Additionally, case managers in public health often were unaware of crisis events in patients’ lives unless the patient reached out to the case manager directly. Notifications of emergency department admissions or inpatient admissions were not possible to view outside of the medical EHR, adversely impacting patient care and outcomes.
To address these challenges, CCHS developed Patient 360 — a single, electronic care team to allow all CCHS staff and providers to view who is involved in patient care across the health care system. It was designed to consolidate information from multiple systems to provide a centralized and comprehensive view of patient services. Through this project, the health system was able to provide real-time notifications of “high-risk” patient events to case managers to enable timely follow-up. By having access to the same information, care teams are able to create a shared patient care plan visible to all care team members incorporating medical, behavioral, and social needs. These advancements allow all members of the team to access user-friendly data dashboards to improve decision-making and health outcomes.
Since June 2018, 859 patients received follow-up by their primary case manager within seven days of being discharged from the hospital. Over 3,000 clients being seen in the homeless system now have identified clinical case managers and more than 26,000 notes from public health nursing visits from 2012 to present are now accessible in the EHR. A unique aspect of the Patient 360 initiative is that a patient’s case manager — nurse, substance abuse counselor, social worker, community health work or mental health clinician — receive high-risk alerts for discharge events. A newly developed standard process has been implemented to follow-up with these patients. Due to the success of this model, Contra Costa is spreading Patient 360 to the rest of the health system.
Ambulatory Care Redesign - Ventura County Health Care Agency
Ventura County faces the highest rate (28%) of chronic homelessness among the general homeless population of all California counties, exceeding the national average. People who are homeless frequently have multiple, overlapping complex physical and mental health needs. Simultaneously, they face many practical barriers accessing services and obtaining needed care — potentially resulting in delayed care, poor outcomes, and higher costs in health care and multiple public services and systems.
For example, a brief analysis of conditions and service patterns among the homeless population showed that 40% had multiple overlapping chronic conditions and co-occurring mental health and 24% had substance use disorders. Fifty six percent had eight or more physical health encounters with the public health care system and 28% had eight or more behavioral health encounters with the behavioral health care system. Forty nine percent were treated in both systems and nearly 50% had no preventive health visits on record.
To address these challenges, Ventura County Health Care Agency worked closely with the community to develop “One Stop” mobile care unitspods. This initiative was developed through consultations with multiple stakeholders, including cities, law enforcement, county agencies and community service providers recognizing that lack of hygiene and basic medical care represented a barrier to housing and other critical services. The program aims to address multiple needs directly in the field where homeless individuals live and congregate rather than waiting for them to seek health care through formal settings.
Mobile “One Stop” outreach and service events, which include medical, behavioral health, and social services such as meals and employment information, are co-located onsite along a mobile shower unit funded and staffed by the Whole Person Care pilot. The mobile shower units engage hard-to-reach, chronic homeless populations and provide a low barrier entry point into services that promote stability. An alcohol and drug treatment specialist counsels and links participants with detox, rehabilitation, medication assisted treatment, and intensive outpatient services. A public health department communicable disease specialist provides on-the-spot testing, counseling, needle exchange, and naloxone overdose prevention kits. Several community organizations offer case management, including needs assessment and enrollment into job training and sober- and transitional-living services. Community volunteers also provide meals, clothing, hygiene supplies, and haircuts.
Since the pilot launched in late December 2017, more than 1,235 clients have been served. All clients have been assessed for housing eligibility and 18 have been successfully housed thus far. Mobile shower services are emerging as a strategy for communities addressing the pressing challenges of homelessness. Some hygiene events provide access to a range of additional supportive services, but few, if any, provide direct access to County-sponsored health, mental health, and social services all in one location. A new pilot “backpack-medicine” with family medical residents at the Health Care for the Homeless clinic is further extending primary care services into the surrounding homeless encampments, serving as many as 150 homeless persons.