Public Hospital Systems: Primary Source for Specialty Care Services (For roundtable information, click here)

California’s 20 public hospital systems make up the core of the state’s medical safety net – delivering care to all who need it, regardless of ability to pay, immigration status or insurance. Though just 6 percent of all California hospitals statewide, public hospital systems provide more than half of the hospital care to the state’s 6.5 million uninsured. In addition to significant inpatient care, California’s public hospital systems provide over 11 million outpatient visits per year.

Much of the care provided at public hospital systems is specialty care. In many communities, public hospital systems serve as the main source of specialty care for Medi-Cal enrollees and the uninsured. In fact, public hospital systems in California account for nearly half of specialty care referrals to hospitals for patients seen at Federally Qualified Health Centers. 1  Nationwide, half of the 31 million ambulatory care visits to public hospitals are for specialty services. 2  With rising numbers of uninsured, an aging patient population with multiple chronic conditions and a greater reliance on the safety net, public hospitals are facing increased demand for specialty care.

To address this issue, many public hospital systems have begun to implement specific strategies to increase access and reduce demand for specialty care services, such as e-referral systems; greater coordination with primary care physicians; and developing clinical referral guidelines.

Specialty Care Access Initiative

In an effort to better understand the current state of access to specialty care and to support movement within the safety net to address the problem, the California Association of Public Hospitals and Health Systems (CAPH), the California Primary Care Association (CPCA) and Kaiser Permanente (KP) formed a partnership called the Specialty Care Access Initiative (SCAI), which is supported by KP Community Benefit. Started in 2006, SCAI seeks to:

  • identify barriers to specialty care access and demand;
  • establish solutions to increase specialty care access and demand;
  • distribute knowledge about barriers and solutions; and
  • create an advocacy strategy for needed change.

To gain an initial understanding of specialty care access issues in California, the Partnership worked with a consultant to develop and gather data through a statewide baseline survey. The data were collected from California public hospital systems and California community health clinics (CCHCs), and have helped SCAI begin to characterize the current state of specialty care access among California’s major safety net providers.

Concurrently, SCAI began to collect qualitative data by hosting statewide roundtable discussions, which provide a forum for public hospital system and CCHC clinicians, administrators, and other stakeholders to spread knowledge, share promising practices, and increase networking opportunities. To date, the roundtables have focused on topics such as E-health, E-referral, Scope of Practice, and Protocols and Guidelines.

SCAI is also collecting additional qualitative and quantitative data through the development of three discussion papers. The first discussion paper, completed in March 2008, addresses expanded scope of practice for primary care providers. The second discussion paper discusses communication, coordination and collaboration between safety net provider systems to address specialty care access. The third will be on the financing and sustaining innovations in specialty care. In addition, SCAI is in the process of creating toolkits and resource guides that will be finalized during the second half of 2008.


1 Felt-Lisk, S., McHugh, M., Thomas, M. “Examining Access to Specialty Care for California’s Uninsured: Full Report.” Prepared for the California HealthCare Foundation, June 2004.

2 National Association of Public Hospitals, “Beyond Primary Care: Specialty Services at America’s Public Hospitals and Health Systems.”

Materials and Resources

Round Table Forum #1: Developing and Managing Effective Referral Systems
Date: Monday, July 30, 2007
Location: Oakland, CA
Materials & Presentations: San Francisco Referral Presentation; LA & Santa Clara Referral Presentations; Minutes

Round Table Forum #2: E-Health
Date: November 5, 2007
Location: Burbank, CA
Materials: Agenda; Attendees; Presenter Contact Information; Minutes
Presentations: Alameda County Blindness Prevention; FHCN Blindness Prevention; KP Remote Telemonitoring; Maximizing E-Health Options; Retinal Telehealth

Round Table Forum #3: Scope of Practice
Date: March 6, 2008
Time: 10AM-3PM (lunch provided)
Location: Doubletree Hotel San Francisco Airport, 835 Airport Blvd., Burlingame, CA  94010, (650) 344-5500
Materials: Agenda; RSVP List ;March Roundtable Notes; Discussion Paper; Family Practice Full Scope-Contra Costa; Timeline for Expanding Scope of Practice-Shasta; Shasta Case 1; Shasta Case 2; Shasta Case 3; Diabetic Referrals-Shasta; Orthopedics Referrals-Shasta; Primary Care Neuropsychiatry Services Work Efficiency Evaluation-Shasta; Model of Care for Neuropsychiatry Services-Shasta; Ambulatory Care Guidelines-Shasta; Expanding Scope of Practice-Redwood Community; Community Clinics Presentation-Marin; Homeless Healthcare Program-Santa Clara Valley; Puentes Clinic Article-Kaiser

Round Table Forum #4: Protocols and Guidelines
Date: June 17, 2008
Location: Sacramento
Materials: Agenda; Attendees; Discussion Paper 2; Southside Coalition Presentation: Early Diagnostic and Intervention Center; Kaiser Presentation: Primary and Specialty Care Interfaces; LA County Online Referral Process Presentation; Meeting Notes

Round Table Forum #5: Workforce Strategies
Date: September 22, 2008
Location: Courtyard Marriott Liberty Station, San Diego
Materials: Agenda; Presenter Contact Information; Specialty Care Within the Medical Home; Recruitment & Retention of Specialty Providers; Promising Scope of Practice: Models for the Health Professions

Round Table Forum #6: Financing
Date: November 3, 2008
Location: Burbank
Materials: Agenda; Presenter Contact Information; Shasta CHC Presentation; All You Need to Know about SC Financing-Aguilera Presentation; San Francisco General Hospital Presentation

For more information, contact:
Mary Gregory, Senior Program Associate
Phone: (510) 874-7104
Fax: (510) 874-7111